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Full text of "Healthy hospitals : observations on some points connected with hospital construction"

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HEALTHY HOSPITALS 



Sm DOUGLAS G ALTON 



Bonbon 

HENRY FROWDE 

Oxford University Press Warehouse 

Amen Corner, E.G. 

H. K. LEWIS 
136 GowER Street, W.C. 




MACMILLAN & CO., 66 FIFTH AVENUE 



HEALTHY HOSPITALS 



OBSERVATIONS 

ON SOME POINTS CONNECTED WITH 

HOSPITAL CONSTRUCTION 



SIR DOUGLAS GALTON 

Late Royal Engineers, K.C.B., Hon. D.C.L., LL.D., F.R.S., Assoc. Inst. C.E., M.I.Mech.E. 

F.S.A., F.G.S., E.L.S., E.C.S., RR.G.S., &-c. 

Forfnerty, Secretary Railway Department Board of Trade 

Assistant Inspector-General of Forttficatio7is 

Assistant Under Secretary of State for War 

Director of Public Works and Btiildings 



WITH ILLUSTRATIONS 



AT THE cLaRENDON PRESS 

SOLD BY HENRY FROWDE 

OXFORD UNIVERSITY PRESS WAREHOUSE, AMEN CORNER, LONDON 

AND BV 

H. K. LEWIS, 136 GOWER STREET, LONDON, W.C. 
1893 






PRINTED AT THE CLARENDON PRESS 

HY HORACE HART, PRINTER TO THE UNIVERSITY 



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PREFACE 



The object which I have had in pubHshing these 
notes on Hospital Construction is to place on record 
those principles which ought invariably to be followed 
in every good hospital, and to point out those condi- 
tions of construction which according to recent practice 
represent the minimum standard required to be fol- 
lowed in building a new hospital. 

These notes do not embody the detailed require- 
ments of hospitals for special diseases, which may entail 
in some cases separation of patients, in others special 
curative adjuncts. They are limited to explaining 
the general principles upon which healthy construction 
must be based. 

Fortunately the tendency of the modern hospital 
architect is not to be content to accept the dicta of his 
predecessor, but to endeavour always to improve upon 
former practice ; and a great development in new 
methods of hospital construction has been the result. 
This tendency has however the drawback, that it has 
not invariably added to the hygienic perfection of the 
structure ; indeed in some recent palatial buildings it 
has been very detrimental, and it has in every case 
added to the expense of hospital construction. It 
seems therefore desirable to bring the fundamental 
principles which should govern hospital construction 



vi Preface. 

prominently before the hospital architect as well as 
before those who are concerned with proposals for 
new hospitals. 

If simplicity of design is the main object which the 
architect keeps in view in following out these principles, 
the cost per bed of new hospitals would certainly be 
much smaller than has been the case in many of those 
which have been recently constructed. This question 
possesses especial importance at the present time, 
because the prosecution of sanitary measures and the 
development of sanitary progress, consequent upon the 
institution of County Councils over the country, render 
it probable that a large number of new hospitals for 
infectious cases and others may ere long have to be 
constructed. 

In pursuing this object it has been necessary to 
consult a large number of authorities, both English and 
foreign. Among these authorities may be specially 
mentioned Dr. Mouat and Saxon Snell, Toilet, Leroux, 
Surgeon-General Billings, Burdett, and Herr V. Kohler, 
Pistor, Bohm, and many others. As it would have 
been inconvenient to refer in the text to every book 
from which information has been sought, it has been 
thought preferable to append a list of many of the 
principal works w^hich have been referred to in the 
compilation of these notes. 



DOUGLAS GALTON. 



12 Chester Street, 

Grosvenor Place, London. 
August, 1893. 



CONTENTS 



PAGE 

CHAPTER I. 
Preliminary 1 

CHAPTER II. 
Defining a Hospital ........ 9 

CHAPTER III. 
Site 21 

CHAPTER IV. 
Conditions which vitiate the Air in an Occupied Room . 37 

CHAPTER V. 
Quantity of Air necessary to mitigate these Conditions 47 

CHAPTER VI. 
Purification of Air 62 

CHAPTER VII. 
Movement of Air ''^ 

CHAPTER VIII. 
Warming ^^^ 

CHAPTER IX. 
Warming (^continued) 11'* 

CHAPTER X. 
Warming {continued) • .121 



viii Contents. 

PAGE 

CHAPTER XL 
Lighting 138 

CHAPTER XIL 
Some of the Methods in which the before-mentioned 

Principles have been applied in Hospitals . . .145 

CHAPTER XIIL 
The Ward Unit — The Wards 174 

CHAPTER XIV. 
The Ward Unit [continued) — Ventilating Inlets and Out- 
lets, Windows, Doors, Walls, and Floors . . .197 

CHAPTER XV. 
The Ward Unit {continued) — Ward Offices , . .213 

CHAPTER XVI. 
Aggregation of Ward Units 224 

CHAPTER XVII. 
Administrative Buildings ....... 239 

CHAPTER XVIII. 

Observations on some Points connected with Hospitals for 
Incurables, Children's Hospitals, Convalescent Homes, 
and Infectious Hospitals 254 

CHAPTER XIX. 
Lying-in Institutions . . . . . . , .265 

CHAPTER XX. 
Remarks on Temporary Structures, and Conclusion . .275 

Index 283 



LIST OF SOME OF THE BOOKS CONSULTED IN THE 
COMPILATION OF HEALTHY HOSPITALS 



Angus Smith 

Baldwin 

Billings 

BiNNIE 

Blyth 

BOHM . 
BOTTGER 
Box . 
Briggs 



BURDETT 



Carnelley 

Carnelley and Mackie 
Carnelley, Haldane, and 
Carnelley and Wilson . 
Clifford-Smith 
Corfield .... 
curgenven 

Curschmann UND Deneke 
Dawson .... 
De Chaumont . 



DONKIN 

Duncan 

Erichsen, J. Eric 
Farr . 
Frankland 
Galton, Sir D. 



Air and Rain. 

Steam Heating for Buildings. 
Ventilation and Heating. 
Mean or Average Rainfall. 
Manual of Public Health. 

Instruction fiir die Behandlung des Ventilationsapparatus. 
Das Kochsche Institut fiir Infectionskrankheiten in Berlin. 
A Practical Treatise on Heat. 
On Rotary Fans. 

On the Relation of Moisture in Air. 
Steam Heating, Ventilating, Halls, Schools, &c. 
Cottage Hospitals. 

Hospitals and Asylums of the World. 
Hospitals and the State. 
Hospital Annual. 

Cost and Efficiency of Heating and Ventilation in Schools. 
The Determination of Organic Matter in Air. (Roy. Soc.) 
Anderson. CO^ Organic Matter and Micro-organisms in Air. 
Micro-organisms in Air. (Roy. Soc.) 
Hospital Management. 
Sewage. 

The Disinfection of Scarlet-fever and other Infectious Diseases. 
Hamburg Hospital. 
Gas Power for Electric Lighting. 
On Ventilation and Cubic Space. 
Theory of Ventilation. (Roy. Soc.) 
Hospitals — Encyclopedia Britannica. 
Measurement of the Velocity of Air in Pipes. 
Spread of Phthisis and Tubercular Disease. 
On Hospital Federation for Clinical Purposes. 
Vital Statistics. 

Influence of Gases on Micro-organisms. (Roy. Soc.) 
Healthy Dwellings. 
Notes on Hospital Construction. 
Report on the Herbert Hospital, Woolwich. 
Report on the Drainage of Cannes. 
Lectures to Royal Engineers at Chatham. 
Some of the Sanitary Aspects of House Construction. 



X 



Books Consulted in Compilation. 



Anstalten und Einrichtungen des offentlichen Gesundheitswesens 
in Preussen. 

Systemes de Chauffage et de Ventilation a I'Hopital La 
Riboissiere. 

Das zweite Garnison-Lazareth fiir Berlin. 

Public Health. 

The Plumber. 

Design for New General Hospital, Birmingham. 

Warming and Ventilation. 

Etude sur las Hopitaux. 

The Works' Managers' Handbook. 
Johnston, Miss, and Prof. Carnelley. Effect of Floor-deafening on the Sanitary con- 
dition of Dwelling-houses. (Roy. Soc.) 

Ueber natiirliche Ventilation. 

Annales d'Hygiene et de Medecine Legale. 

Les Matemites. 

Hopitaux Marins. 

Dusty Air in the neighbourhood of Illuminated Bodies. 

Sanitary drainage and Plumbing. 

Circular Wards. 

Typhoid Fever and Tropical Life. 

Medical Service in Modern War. 

Welche Aufgaben erfullt das Krankenhaus der kleinen Stadte 
und wie ist es einzurichten ? 

Manual pratique du Chauffage et de la Ventilation. 

On the Ventilation of Public Buildings. 

Ventilation, Proc. Inst. C. E., vol. xliv. 

Hospital Construction and Management. 

Notes on Lying-in Institutions. 

Notes on Nursing. 

Hygiene publique. 

Hygiene. 

Heating and Ventilating the Glasgow University. 

Notice on Dr. Van Heecke's System of Warming and Ventilation. 

Journal d'Hygiene. 

Studien uber Krankenhauser. 

A System of Ventilation. 

La Construction des Casernes. 

Dictionary of Medicine and Nursing. 

Practical Sanitation. 

Hot-water Apparatus. 

Dictionnaire de Medecine et Chirurgie. 

Charitable and Parochial Institutions. 

Manual of Heating and Ventilation. 

Ventilation and Warming of Buildings. 

Journal Statist. Soc, vol. xl. 
Murphy. Hygiene and Public Health. 

Warming and Ventilation of Public Buildings. 

Public Health Problems. 

Hospital Mortality. 

Dictionnaire d'Hygiene Publique. 

Les Nouvelles Maternites. 



GOSSLER und PiSTOR 

Grassi . . . . 

Gropius und Schmieden 

Guy . 

Hellyer 

Henman 

Hood . 

HUSSON 

Hutton 



Lang . 

La YET . 

Lefort 

Leroux 

Lodge and Clark 

Maguire . 

Marshall . 

Marston, Surgeon-Gen 

Mencke 
Morin 

Morrison . 

Mouat and Saxon Snell 

Nightingale, Miss 

Palmberg . 

Parkes 

Phipson 



Pietra Santa . 

Plage 

Potts 

Putzeys, Drs. F. et Em. 

QUAIN 

Reid .... 

Rosser and Russell 

Sarrazin . 

Saxon Snell . 

Schumann . 

Smead 

Steele ... 

Stevenson and Shirley 

sutcliffe . 

Sykes ... 

Tait-Lawson . 

Tardieu . 

Thevenot . 



Books Consulted in Compilation. 



XI 



Trelat 
Trotter 

TUSON 

Waddington 

Wallace . 

Waring 

Watson 

Werner et Schutte 

Whitelegge 

WiLLOUGHBY 

Wolpert . 



TiEDEMANN . . . Die medicinischen Lehrinstitute der Universitat Halle. 

TOLLET .... Les (Edifices hospitallers depuis leur origine jusqu'a nos jours. 

La Reforrae du Casernement. 

Les Hopitaux. 

The Distribution and Measurement of Illumination. 

Efficacy of Sulphur in Epidemics of Cholera. 

Burnley and Southport Hospitals. (Designs.) 

Sanitary Engineering in India. 

Sewage Disposal for Isolated Houses and Large Institutions. 

Disposal of Refuse. 

De Tame'nagement intcrieur d'un Lazaret Portatif. 

Hygiene and Public Health. 

Health Officer's Pocket Book. 

Ventilazion und Heizung. 

Reports and other Detached Papers :— 

Cubic Space of Metropolitan Workhouses, 1867. 

Sanitary State of the Army in India, Report and Appendix, 1863. 

Report of British National Society for Aid to Sick and Wounded, Franco-German 

War, 1870-1871. 
Reports of Medical Officer of Privy Council, 1864, et seq. 

,, „ „ „ Messrs. Bristowe and Holmes. 

,, „ „ „ ,, Thorne and Power. 

Small-pox and Fever Hospitals' Report, 1882. 
Report on the Sanitary Condition of the Army, 1858. 
Sanitary Reports, Army Medical Department, 1869-91. 
Barrack and Hospital Commission Reports, 1858-1862. 
British Medical Journal, Builder and Lancet. 
Official Report, Smoke Abatement Committee, 1882. 
Report of Ninth International Medical Congress in Washington, 1887. 
Sanitary Engineer, New York. 
International Congress of Hygiene, 1891. 
Ueber zweckmassige Einrichtungen von Kliniken. 
Army Sanitary Commission, Condition of Barracks and Hospitals. 
Allgemeine Grundsatze fiir den Neubau von Gamisonlazarethen. 
Construction and Maintenance of School Infirmaries and Sanatoria. 
Sonder-Abdruck aus der Deutschen Vierteljahresschrift fiir offentliche Gesund- 

heitspflege. 
Heating and Ventilating Apparatus, Union League Club, New York. 
Ventilation of the Small-pox Hospital Ship ' Castalia.' 
Salford: Description of Ladywell Sanatorium. 



HEALTHY HOSPITALS. 



CHAPTER I. 

PRELIMINARY. 

Hospitals for the reception of sick and injured date from 
very early times. The Buddhist religion, which overspread 
India 400 years before the Christian era, gave rise to numerous 
conventual establishments, containing many thousand monks; 
these were in some cases practically Universities. In them 
Science, Medicine, Philosophy, and Law were taught, as well 
as Theology. Great Public hospitals were established in 
every city which afforded facilities for continuous study. 
Discoveries of celebrated drugs and remedies as well as the 
power of treating difficult surgical operations with boldness 
and skill resulted from this experience. 

Military hospitals appear to have been first established for 
the Roman armies in the time of Trajan. 

At Delos we read of a Lying-in hospital. St. Jerome 
mentions a hospital built by the Roman matron Fabiola 
360 years after Christ, and the Emperor Valens is said to 
have richly endowed a hospital at Cassarea about 370 years 
after Christ. In the ninth century there were twenty-four 
hospitals in Rome. These hospitals seem to have been 

B 



2 Healthy Hospitals. [ch, 

under the Deacons supervised by the Bishops. In Paris 
the Hotel Dieu dates from the Merovingian Kings, and in 
660 it received from Archambaud, Count of Paris, the gift 
of his Palace and Chapel, and was further enlarged by the 
architect Adam, under King Philip Augustus II, in 1198. 

In 1 153 there were established hospitals at Chartres and 
Angers in the form of a cross. At Ourscamp about the same 
time a hall was built to accommodate 100 sick and injured 
persons, which was 144 feet long, 64 feet wide, and '^'>^ feet 
high, affording 92 superficial feet per bed. 

Margaret of Burgundy established a hospital at Tonnere, 
nursed by Sisters of Mercy, where the beds were placed 
along the sides of the Hall each in its own compartment 
surrounded with curtains. 

The appearance of the plague in France in 1360 caused 
a great addition to the hospitals. Those for isolation 
purposes were generally situated outside the towns, and were 
subsequently used as lodgings by strangers who came to the 
towns after the gates were closed at night. 

In this country St. Bartholomew's Hospital was founded in 
1 1 25. The principal existing hospitals in England date 
however from periods between 1700 and the middle of the 
present century ; but many hospitals of the last and of the be- 
ginning of this century have been entirely rebuilt during the 
last twenty or twenty-five years ; it may be further observed 
that a great development has taken place during recent years 
in Cottage hospitals for Villages and in Isolation hospitals for 
infectious diseases. 

It is not, however, intended here to give a history of the 
progress of hospital construction since early times. That 
will be found in M. Toilet's beautiful book, Mr. Burdett's 
comprehensive work, and in other publications. We desire 
only to show in a succinct manner what are the principles 
of hospital construction which have been developed in late 
years by the careful consideration that has been given to 



1.] Preliminary. 3 

the causes of disease, their prevention and cure. But before 
proceeding to discuss this question we may recall a few of 
the considerations which have led to the present form of 
hospitals. 

The shape and disposition of wards which have been 
arrived at in recent years were worked out after experience 
had shown the importance of these forms, rather than as a 
consequence of a preconceived theory. 

The fact is that our present system of hospital construction 
mainly owes its rise, in this country at least, to the 
experience derived from the wars of the last and present 
century, where large numbers of sick and wounded were 
collected together in extemporised hospitals. Dr. Brocklesby 
had shown as early as 1758, and Sir John Pringle and 
other military surgeons later on, that hospital huts and tents, 
in which the patients were exposed to unfavourable conditions 
from cold and wet, produced more numerous and rapid re- 
coveries from wounds during these wars, and from the diseases 
incidental to camps, than the permanent hospital buildings 
then in use. 

But it was mainly in consequence of the experience of the 
Crimean War, the American War of Secession, and the 
Franco-German War of 1870-71, that physicians and sur- 
geons generally became impressed with the importance of so 
arranging the buildings for sick and wounded that they should 
be constantly under the favourable influence of fresh air and 
cleanliness. 

There is abundant evidence that the agglomeration of sick 
and wounded men into the permanent buildings used as hos- 
pitals during these wars was very destructive of life, while it 
was seen that wounded recovered best when scattered among 
cottages, attended almost entirely by the people, notwith- 
standing that they were often indifferently fed ; and it was 
found far better to place wounded men, as a rule, in detached 
buildings, or even under a canvas roof, or any similar shelter 

B a 



4 Healthy Hospitals. [ch. 

sloping from a barrack or church wall, than to take them 
inside the building even in cold weather. 

In some of the reports on the reconstruction of the Hotel 
Dieu in Paris made before the breaking out of the Revolution, 
the objection to massing together large numbers of patients 
in one building was strongly urged, and instances were given 
in official reports of the evil influences of the sick upon 
each other. Cases were quoted in which persons whose beds 
were placed not far from wards which contained patients ill 
with putrid fever, did not get cured at all, or were cured with 
great difficulty. 

No doubt many of the early hospitals were of the pavilion 
form of construction, so far as placing windows on opposite 
sides is concerned, but a very large number of beds were 
placed in several rows in one long room or gallery, and under 
one roof. 

In this country the earliest specimen of a hospital on a 
pavilion system, with a limited number of patients in each 
pavilion building, appears to have been built for sailors, at 
Stonehouse, near Plymouth, by an architect named Rovehead, 
between the years 1756-64. In this building the ends of the 
pavilions were united by a covered corridor to protect persons 
passing from one pavilion to the other. 

This hospital was based on the principle of limiting the 
number under one roof, and was a practical protest against 
the plan then largely prevalent, chiefly on the Continent, 
of agglomerating a large number of sick or injured in one 
large hall. But it did not embody the cross ventilation of our 
present pavilion construction. 

This form was not, however, followed generally in this 
country, and the corridor system with rooms, each containing 
a limited number of sick, opening out of a common corridor, 
arranged apparently with the object of facilitating the inter- 
change of vitiated air, appears for a long time to have been 
preferred — a system which culminated in Netley in 1856. 



I.] Preliminary. 5 

This was not the case in France. In that country the 
excellent work of M. Toilet shows that the pavilion principle, 
as now understood, was suggested as far back as 1750, with 
wards limited to about thirty-four beds in each. 

In the American War of Secession long wooden huts^ 
erected for receiving the sick and wounded, were resorted to 
instead of existing brick buildings. 

The Lower General Hospital of Philadelphia consisted of 
a series of one-storied huts disposed round an interior area, 
in which the offices and abodes of the administration were 
situated. 

The site was a high and airy plateau, on which fifty huts 
afforded accommodation for 500 patients. These huts were 
arranged like spokes of a wheel around a central corridor, 
and open freely to the air, but closed and warmed in winter 
by stoves ; this corridor afforded, at all seasons, a pleasant 
lounge for the convalescent patients. 

A tramroad ran round the corridor, on which waggons 
brought the food and supplies to the end of each hut-ward 
without delay. 

A telegraph connected the huts and the kitchen with the 
director's office and other parts of the administration. 

A branch from the railroad permitted the railway cars, in 
which the patients had been laid near the battle-field, to dis- 
charge their freight at the door of the hospital ; thus the 
patients suffered only one change, from the railway to their 
beds. 

It was upon this model that the German temporary hos- 
pitals were organised during the Franco-German war. In 
this war the want of suitable hospitals led to the erection of 
a large number of buildings of wood, as well as to the use of 
tents. Neuwied, Frankfort, Mannheim, Heidelberg, Darm- 
stadt, and Aachen afforded some very good examples of 
extemporised hut hospitals. 

In all these the arrangement aimed at was to give the 



6 Healthy Hospitals. [ch. 

patient as much fresh air as possible. The sides were in 
many cases capable of being entirely opened, and were kept 
open till late in the autumn. Along the ridge a very large 
space was devoted to the admission of air. Where the sides 
were continuous, and there were windows, a large opening for 
fresh air was reserved along the eaves, and frequently also 
along the floor. The floor was always raised from two to four 
feet off the ground. 

Some surgeons, in addition to the arrangements for securing 
fresh air in the huts, caused many of their patients to be carried 
in their beds by day into the adjoining meadow, and would 
willingly have kept the wounded in the open air through the 
winter, but the nurses could not stand the cold. 

These hospitals, although crowded with wounded, pre- 
sented scarcely any cases of pyaemia or hospital disease so 
long as they were permeated by fresh air. But curiously 
enough, as soon as the winter set in with severity, the ad- 
vantages of fresh air were ignored, the sides and even the 
windows were nailed up, leaving only one or two moveable 
ventilators at the top of the building, and a nurse employed 
in one of them said, — ' The air was so utterly foul and corrupt, 
that a feeling of nausea came over me each time I entered 
them'; and during the winter hospital diseases made their 
appearance. 

There is no question but that the experience of the ad- 
vantages of fresh air in hospital wards, gained during these 
wars, has led the medical profession to approve of the present 
pavilion system of hospital construction. 

There does not appear to be any very definite view as to 
the extent of hospital accommodation which is necessary 
to be provided in proportion to the population. According 
to Mr. Burdett and other authorities, there should be one bed 
to every i,ooo inhabitants for general diseases and surgical 
cases. The whole hospital accommodation of London, ex- 
clusive of Infectious hospitals, may be said to aflbrd about 



I.] Preliminary. 7 

one bed to every 800 inhabitants. In some counties the pro- 
portion is only one bed to 2000 inhabitants, and in others, if 
we include the workhouse infirmary, it approaches within 
measurable distance of Mr. Burdett's standard. Of course 
this provision refers to an average ; and in a village of say 
500 or 1,000 inhabitants, if a cottage hospital were provided, 
three or four beds at least would be necessary. 

It is quite certain that many persons, even of the fairly 
well-to-do class, would have much better chances of recovery 
from either sickness or injury in a well-administered hospital 
than in their own homes. This is especially the case with 
the less well-to-do. For infectious or contagious diseases, 
where early separation of the sick from the healthy is of 
paramount importance, a hospital is a necessity. In the case 
of small-pox and scarlet fever, unless provision for isolation is 
sufficient to permit of the earliest cases being weeded out at 
once, the prime object of an Infectious hospital is not attained. 
In the case of Infectious hospitals the ratio given by Mr. 
Netten Radcliffe as desirable was about twenty beds for a popu- 
lation of 35,000. In twenty-seven important towns, having a 
total population of nearly 4,500,000, there are twenty infectious 
beds to each 29,000 persons. This seems too small in the 
event of epidemics. As a matter of fact London at the present 
time has nearly 4600 beds in the hospitals of the Metropolitan 
Asylums Board. This, on Mr. Netten Radcliffe's calculation, 
should be sufficient for a population of 5,700,000, which is 
more than the population of the Metropolitan area. But the 
hospitals of the Metropolitan Asylums Board are overcrowded 
when an accession of scarlet fever occurs, accompanied by 
that of any other disease, as for instance in the autumn of 
1892, when there was at the same time much diphtheria, and 
provision was also required to be made in anticipation of 
cholera. From this experience it may be inferred that a 
larger proportion of beds, either by temporary provision or 
otherwise, is necessary to meet such an emergency. It would, 



8 Healthy Hospitals. 

however, be costly to provide, and to keep up permanently, 
sufficient accommodation to meet the occasional contingency 
of epidemics. 

The reasonable course would seem to be, that the per- 
manent provision should suffice for an average number of two 
or three simultaneous infections, and that this should be sup- 
plemented by temporary arrangements in case of need. Late 
authorities have proposed that infectious accommodation 
should be provided in the proportion of ten beds per 10,000 of 
population, with arrangements framed to admit of three dif- 
ferent infections in both sexes. 

The case of cholera involves other considerations. It is 
worthy of note that the removal of the patients to hospital 
does not find favour with those who have had experience in 
the treatment of this disease. The act of removal is attended 
by fatigue, which during an attack of cholera appears to re- 
duce the probabilities of recovery. In such cases it might 
be preferable to leave the patient in his own home, and to 
make provision elsewhere for the healthy occupants of the 
house. 

It may, however, be observed that both cholera and enteric 
fever might, with proper precautions, be treated in General 
hospitals, in isolation wards, a course which would not be 
advisable in the case of scarlet fever and small-pox. 



CHAPTER II. 



DEFINING A HOSPITAL. 



A Hospital is not only a place for the reception and cure 
of the sick poor ; it has, so far as the community is concerned, 
another very important function. 

It is the technical school in which the medical student 
must learn his profession, and it is an experimental workshop 
in which the matured physician or surgeon carries on scientific 
research. 

As a place for the reception and cure of the sick or injured, 
who do not possess facilities for being nursed at home, the 
hospital should be so arranged as to possess conditions more 
favourable for recovery than such persons could otherwise 
command in their own homes. 

The care of the sick and injured, which in the time of the 
Egyptians, Greeks and Romans, seems to have been connected 
with the religion of the people, has in these later days, especially 
in this country, been mainly the attribute of the charitable. 

Our principal institutions, where they do not possess en- 
dowments, such as are possessed by St. Bartholomew's, St. 
Thomas's, and Guy's Hospitals, have necessarily to depend 
for their maintenance upon the contributions of the public. 
Our Infectious hospitals and Poor Law infirmaries, on the 
other hand, are built and maintained out of the rates. These 
institutions in London have not hitherto been adapted to 
the very important objects which a hospital fulfils in edu- 
cating the medical student. 

It must be remembered that in other professions the 



lo Healthy Hospitals. [ch. 

student can pursue his studies largely in his library, but for 
the medical student the patients are the books out of which 
he has to read at the bedside, and hence it is of essential 
importance to the community that every hospital should 
be available for study. It is, however, true that recently, in 
consequence of the absorption of all infectious cases into the 
Metropolitan Asylums Board and the impossibility therefore 
of students having the opportunity of studying these diseases 
outside, some small provision has been made for students in 
these hospitals. 

In towns of moderate size an individual interest is taken 
in the hospital or infirmary, and the county population sur- 
rounding the town, which is in a position to derive advantage 
from the hospital, willingly contributes to its maintenance. 
But London has in a great measure outgrown this feeling of 
individual interest. The supporters of many of the hospitals 
now necessarily often reside far from them. The poor in 
their immediate vicinity have not the means or inclination to 
give substantial support. The new Workhouse infirmaries 
and the Asylums Board hospitals are gradually impressing 
on the poorer classes the feeling that they ought to be treated 
for illness at the expense of the community. 

The necessities of the hospitals grow daily with the grow- 
ing population, but the funds do not proportionately increase. 
Hence important questions arise as to their future main- 
tenance. 

Some influential persons have advocated that the subscrip- 
tions for hospitals should all be collected by a central 
federated committee, by whom they should be distributed 
to the several hospitals. Such a system would probably 
soon dry up all that remains of individual effort, and the only 
solution of the question then would be for all the cost of the 
hospitals to be borne on the rates, and for the parochial 
authorities to partly recoup themselves by charging a reason- 
able sum to every patient who could afford it. 



II.] Defining a Hospital. \ i 

In Paris, when in the Revolution of 1789 the charitable 
and other endowments shared the same fate as our monas- 
teries under Henry VIII, the State had ultimately to make 
some provision for the sick poor. And at the present day 
all the hospitals are under the direction and control of an 
Administrative Council, subject to the Prefect of Paris and 
ultimately to the Minister of the Interior, while the necessary 
funds are supplemented annually by votes in the budget, a 
legal power being given to assess patients admitted to a pro- 
portion of the cost of maintenance apportioned to their means. 

In Sweden the hospitals are managed by separate govern- 
ing bodies, as in London, but submitted to a State control so 
far as necessary to insure a certain unity of system and 
administration, and especially as regards finance and account- 
ability. A scale of charges is also established, and all pay 
something except the really poor. The first class pay a 
substantial sum, as now in our paying hospitals ; the second 
pay less, but still a remunerative sum. 

Without entering further into these questions it may be 
admitted that it certainly would seem desirable that those 
patients who can afford it should contribute to their treat- 
ment when in hospital. 

This principle is endeavoured to be enforced in our In- 
fectious hospitals in London. They are built and maintained 
out of the rates ; the cost of each patient is charged to the 
parish whence he comes, and the parochial authorities call on 
those patients, who can afford it, to repay them their contri- 
bution. The argument for payment in these Infectious 
hospitals is not, however, so strong as in other hospitals, 
because they are established as a protection to the commu- 
nity rather than for the advantage of the affected individual ; 
and enforced payment tends to discourage resort to them. 
Whether, however, the Hospital is supported by voluntary 
effort, or whether it is supported by the rates, the necessity 
for economy in management is apparent, and it follows as an 



12 Healthy Hospitals. [ch. 

important feature of hospital construction that the building 
should be so arranged as to enable a small staff of medical 
men, nurses, and assistants to minister to the wants of a large 
number of sick. This can only be done by bringing many 
sick together in one establishment, and, except in special 
cases, placing several sick in one room. 

The attention which has been given of late years to the 
management of sick and injured persons, in connection with 
the investigations which have taken place into the causation 
of disease, have led to a considerable development of the 
practical application of hygienic principles to hospital con- 
struction. 

These general principles of construction may be assumed 
to be similar under all circumstances. That is to say, in 
every hospital it is necessary that the building be so 
arranged that it shall stand on a pure soil ; that it shall be 
supplied with pure water; that it shall be permeated with 
pure air ; and that its cleanliness shall be ensured by 
abundance of light. 

There must, however, be a division between certain classes 
of patients. For instance, it may be desirable to keep in 
separate classes — 

(i) Contagious and infectious diseases, possibly including 
phthisis. 

(a) Ordinary sick. 

(3) Injured or wounded. 

(4) Aged sick poor. 

{^) Lunatics and imbecile. 

(6) Pregnant women, who are not suffering from disease in 
the ordinary sense. 

(7) Convalescents'. 

And there are further subdivisions which are necessary as 
regards infectious and contagious diseases. 

It is noteworthy that the Infectious or Contagious hospital 
was at one time a necessary adjunct to every small community. 



II.] Defining a Hospital. 1 3 

With the diminution in the number of the violent outbreaks 
of such diseases, consequent upon the improved habits of 
cleanhness in the population, these lazar or pest houses fell 
into disuse, and it is only now that we are awakening to the 
necessity of again making such establishments an appendage 
of every Sanitary Authority, and, unlike the case of general 
hospitals, charging the cost of their construction and mainten- 
ance to the rates. 

In these hospitals small-pox should be separated from 
scarlet fever and diphtheria. Some forms of ophthalmic 
disease require separation. Subdivisions may also be neces- 
sary in the case of the sick admitted to General hospitals. 
For instance — the temperature to be maintained for those 
suffering from bronchitis and pulmonary complaints may differ 
from that for other cases of sickness, and so forth. 

Hence the class or character of disease to be treated may 
require a special application of these general principles ; and 
this has led to the adoption of separate hospitals, suited to 
various classes of patients, and various categories of disease. 

Existing hospitals may be said to fall under the following 
general heads : — 

A. Those connected with treatment and cure of disease, 
each of which may be assumed to require special arrange- 
ments. 

(1) General Hospitals, with a medical and surgical side, 

with which must be grouped the small Cottage 
hospitals, which have attained a certain extension, 
in recent years, both in this country and elsewhere. 

(2) Children's hospitals with a similar division of medical 

and surgical cases. 

(3) Infection hospitals. 

(4) Lying-in hospitals. 

(5) Convalescent hospitals. 

(6) Seaside hospitals for treatment of lymphatic and 

scrofula patients. 



14 Healthy Hospitals. [ch. 

(7) Special hospitals for surgical treatment — as ophthal- 
mic, orthopcedic, dental, and otherwise. 
In connection with these it may be desirable to mention 
dispensaries, either provident or otherwise, and assistance to 
be rendered where patients are treated at home. 

Workhouse infirmaries have also received extended de- 
velopment in late years, but these are mainly for paupers and 
charged to the rates ; whilst Military and Naval hospitals are 
a necessary appendage to every garrison and naval port ; and 
Field hospitals the necessary accompaniment of every army. 

B. Those hospitals which are more in the nature of 
permanent refuges : — 
(i) For Incurables. 

(2) Imbecile Asylums. 

(3) Lunatic Asylums. 

It is beyond the province of this book to discuss the 
detailed construction of all these various institutions, but 
there are certain general considerations which affect all 
hospitals, and it is to these principles that it is now proposed 
to direct attention. 

The first object of a hospital, as has been already 
mentioned, apart from its function as a teaching institution, 
is to enable the sick to recover in the shortest possible time. 

In a treatise on hospital nursing, Miss Nightingale observes 
that — ' Sickness or disease is Nature's way of getting rid of 
the effects of conditions which have interfered with health. 
It is Nature's attempt to cure ; we must help her.' 

In addition, therefore, to being supplied with the most 
complete curative appliances, the hospital should furnish all 
those conditions which are wanted to enable Nature to set up 
her restorative processes, and to put the patient in a condition 
to recover. 

These conditions are summed up by Sir John Simon, the 
former Medical Officer of Health to the Privy Council, in the 
following apt words : — ' A healthy hospital is one which 



11.] Defining a Hospital. 15 

does not by any fault of its own aggravate ever so little the 
recovery of persons who are properly its inmates. The faults 
by which a hospital fails to attain to the best results for its 
medical and surgical treatment may be of two kinds — either 
it is an inherent fault as of site and construction, or else it is 
a fault of keeping, as dirtiness or overcrowding, or neglect of 
ventilation.' 

There are in existence many hospital buildings which, 
although they are not well calculated by their form to allow 
of the free permeation of fresh air, and to which light does 
not readily penetrate to all parts, yet show a record of 
favourable recoveries, owing to the larger floor space which is 
allotted to patients in the wards, to the judicious use which 
is constantly made of such means of aeration as exist, 
and to the scrupulous cleanliness which is maintained in every 
part of the building. 

Cleanliness and fresh air do not so much give life as they 
are life itself to the patient. Cleanliness — clean air, clean 
water, clean surroundings — and a fresh atmosphere everywhere 
are the true safeguards against ' infection ' ; segregation by 
ample floor and cubic space, ample ramparts of fresh atmo- 
sphere, rather than segregation by walls and divisions. You 
cannot lock-in or lock-out the infectious poison. You can 
air it out, diffuse it, and clean it away. In order to facilitate 
the maintenance of healthy conditions in a hospital the form 
of the building should be such as to ensure the provision and 
proper application of 

(i) Fresh air, with the necessary warmth and coolness. 

(2) Ample light '* icluding the penetration of sunshine to 
every part, 

(3) Purification o. floors and walls. 

(4) Means of personal cleanliness. 

(5) Adequate bed and bedding maintained absolutely 
clean, and adequately prepared food and drink. 

(6) Attendance. 



1 6 Healthy Hospitals. [ch. 

The constructional arrangements which bear on these 
various matters may be conveniently summed up under the 
following heads : — 

(i) The soil on which the hospital stands should be clean, 
that is to say, the soil should neither emit, nor should it be 
exposed to any injurious emanations. 

(2) The surrounding air should be pure, and there should 
be no appreciable difference in purity between the air inside 
and that outside the building. 

(3) The pure air supplied to the wards, corridors, and 
offices should be capable of being warmed to any required 
extent. 

(4) The water supplied for use should be pure, and after 
use it should be removed with its impurities to a distance 
from the hospital. 

(5) Perfect cleanliness should prevail within and around 
the building. 

In respect of the importance of cleanliness, the following 
extract from the report of Sir John Simon deserves notice : — 
' That which makes the healthiest house, makes likewise the 
healthiest hospital ; the same fastidious and universal cleanli- 
ness, the same never-ceasing vigilance against the thousand 
forms in which dirt may disguise itself in air, and soil and 
water, in walls and floors and ceilings, in dress and bedding 
and furniture, in pots and pans and pails, in sinks and drains 
and dustbins. It is but the same principle of management, 
but with immeasurably greater vigilance and skill ; for the 
establishment which has to be kept in such exquisite per- 
fection of cleanliness is an establishn. it which never rests 
from fouling itself ; nor are there any ducts of its foulness 
— not even the least odorous of such .roducts — which ought 
not to be regarded as poisonous.' 

The number of the inmates in a hospital — the number col- 
lected under one roof^the shape of the hospital buildings, 
and their distribution in regard to each other, and the 



II.] Defining a Hospital. 17 

methods of administration, all materially affect the preserva- 
tion of the purity of the air. The best index to the relative 
efficiency with which this purity is maintained in different 
hospitals would probably be an equation in which the mor- 
tality and the length of time required for recovery of patients 
would form the chief factors. 

But the facts of medical science are complex in their nature 
and liable to be influenced by an infinite number of collateral 
and minor considerations. Attempts therefore to compare 
large hospitals with small, to show the superiority of one 
form of construction over another, based on results derived 
from their mortality as at present ascertained, or on the 
average length of time cases are under treatment, are as yet 
too deficient in scientific accuracy to afford reliable data for 
the solution of this problem. 

As has been already mentioned, we meet with hospitals 
converted from ordinary houses, where a scrupulous attention 
to cleanliness and the maintenance of a large floor space in 
the wards have produced satisfactory results. Other statistics 
have been adduced to- show that the small cottage hospitals 
have produced fewer deaths and more rapid recoveries than 
larger town hospitals ; but those statistics did not suffici- 
ently bring into comparison the nature of the cases treated 
in each hospital, the form of the wards, the degree of clean- 
liness and of excellence of maintenance and nursing in each 
hospital. 

As a general rule, however, it is quite certain that those 
hospitals in which the external architectural design had been 
the first care of the architect and the free circulation of air 
a secondary consideration, have produced results in deaths 
and in difficulty of cure far exceeding those which take 
place in hospitals where the architect has endeavoured, in 
the first instance, to arrange a plan which will secure free 
permeation of fresh air and an absence of dark corners as the 
normal condition of the building. 

C 



1 8 Healthy Hospitals. [ch. 

With these prehminary remarks we will proceed to consider 
the conditions which should regulate — 
(i) The site of the proposed hospital. 

(2) The form of the rooms in which the sick are to be 
placed and nursed, so as to ensure purity of air and convenience 
of nursing ; because these rooms form the principal units of 
hospital construction. 

(3) The distribution of these units, and of the other neces- 
sary accessories, which when combined constitute the hospital. 

As a preliminary to these questions it will be convenient to 
mention what are the several parts of which a hospital may 
be said to be composed, bearing in mind that simplicity of 
design should be one of the aims of the hospital architect, 
and that any useless multiplication of administrative offices 
can only lead to complication of administration, confusion of 
the departments, and needless expense. 

The several parts of a hospital may be classed as follows : — 

I. Those connected with the admission and treatment of 
the sick. 

(i) Rooms for reception and examination and for dis- 
charge of patients. 

(2) The wards and their appurtenances. 

(3) Baths for treatment, including medicated, Turkish, 

vapour, electric, &c. 

(4) Operation room and its adjuncts. 

(5) Dispensary and drug store. 

(6) Splint store and workshop. 

(7) Mortuary and its adjuncts. 

(8) Out-patients' waiting room and the various rooms 

for their examination and treatment ; where an out- 
patients' department exists. 

II. Connected with boarding and clothing of patients, 
(i) Kitchen with its adjuncts. 

(2) Stores of food, fuel, linen, patients' clothes. 



II.] Defining a Hospital. 19 

(3) Laundry. 

(4) Disinfection. 

(5) Destruction of refuse. 

(6) Servants' accommodation, male and female bedrooms, 

dining rooms, sitting rooms, &c. 
III. Connected with nursing accommodation. 

(i) Nurses' rooms or Nurses' home with bedrooms, 

dining room, sitting room, library and lecture room. 
(2) Probationers' rooms in connection with training school. 

IV". Connected with Medical Education, 
(i) Post-mortem room. 

(2) Preparation room and laboratory. 

(3) Museum and library. 

(4) Lecture room. 

(5) Students' waiting rooms and Cloak rooms. 

V. Connected with General Supervision. 

(i) Accommodation for meetings of Governing body, 
and for Secretary, Accountant, the keeping of 
Registers, &c. 

(2) Rooms for Medical Staff, resident and non-resident. 

(3) Apartments of Matron, or Superintendent of female 

staff connected with service of hospital. 

(4) Arrangements for controlling ingress to and egress 

from Hospital. 

The wards are the units which govern the general shape of 
a hospital, and the shape of the wards is therefore the first 
point to be settled. 

The form and size of the wards depend upon the air- 
space required for each individual patient placed in the ward, 
and upon the way in which this air-space is distributed 
round him. This air-space is governed by the questions 
involved in the renewal of air, and these are affected by the 
methods adopted for the introduction of fresh air and the 
arrangements for warming the wards. 

C a 



20 Healthy Hospitals. 

These questions are so vital to the form of the wards that 
it will be desirable to consider them before discussing the 
shape of the wards. 

They may be described under the following heads : — 
(i) Conditions which vitiate the air in an occupied room. 

(2) Quantity of air necessary to mitigate these conditions. 

(3) Movement of air — 

(a) by natural means, 

(/3) by artificial appliances. 

(4) Conditions which regulate the warming of air. 

But in the first place we must consider the conditions 
which regulate the choice of the site on which the hospital 
should stand. 



CHAPTER III. 



SITE. 



The site to be selected for a hospital depends upon various 
considerations, and cannot be determined merely by its 
physical condition. 

On the one hand, in order that the curative art may be 
carried on under the most favourable circumstances and with- 
out disturbing causes, it is necessary that the hospital building, 
in which the patients are lodged, should be furnished with the 
most complete appliances, and that it should be placed in the 
most favourable hygienic conditions. If these latter conditions 
are to be fully ensured, the hospital should be in the open 
country, and if health considerations alone are to prevail, 
no hospital would probably be located in a town. But, on 
the other hand, a hospital must be so placed that it will be 
conveniently available for the reception of the sick poor, and 
in the case of accidents, and of many diseases such as enteric 
fever, scarlet fever, pneumonia, cholera, &c., it is of im- 
portance that the distance which the patient has to be con- 
veyed shall be as short as possible. 

The hospital should also be easily accessible to the 
physicians and surgeons, both to enable them to prosecute 
the study of their profession, and to give clinical instruction to 
the Medical Students. The leading physicians and surgeons 
of a town necessarily reside near the more crowded localities. 

These conditions would require that hospitals should be 
placed in centres of population. Consequently, one of the 



2 2 Healthy Hospitals. [ch. 

principal considerations in determining the position of a site 
for a General hospital is proximity. 

Other classes of hospitals, including Cottage hospitals, for 
comparatively scattered rural populations. Asylums, or hos- 
pitals where the treatment is for special diseases, are not 
similarly fettered. 

In the case of Isolation hospitals for small-pox and fevers, 
whilst it is desirable that the patients should not be transported 
to great distances by road, yet it is of importance that, where 
it can be avoided, they should not be treated in centres 
of population ; besides which these institutions are always 
objected to, mainly on grounds of sentiment, as disagreeable 
neighbours. Hence, when the size of a town admits of it, 
they are placed in the open country. But in London, the 
great distances to be traversed render this impossible, in the 
case of those infectious diseases which would especially suffer 
from a long land-journey. 

Convalescent hospitals are placed in the open country, or 
by the sea-side. In England there are such hospitals, both 
for adults and for children, at Margate, Hastings, and other 
sea-side places ; whilst in France and Italy there are numerous 
Marine hospitals, where children of lymphatic nature, or those 
suffering from scrofula, rickets, or tuberculosis, are treated. 
Indeed, the municipality of Paris has for many years had 
a hospital of i,ioo beds at Berck-sur-Mer, in the Pas de 
Calais. 

The asylums for imbeciles or lunatics are similarly placed 
in the open country. 

The consideration of proximity must, however, be controlled 
to a great extent by physical conditions, and therefore in 
selecting a site for a hospital it is essential, where the con- 
ditions admit of it, to test the healthiness of a proposed site, 
by enquiry into the rate of mortality in the district ; as well 
as the prevalence of sickness, and the nature of the diseases. 
Whenever this information can be satisfactorily obtained, it 



III. J Site. 23 

would afford a ready and effectual means of ascertaining the 
suitableness of a site for the sick. On the assumption that 
the choice of a site is unfettered, except by hygienic require- 
ments, the qualities of a site most favourable to a hospital 
may be described to be a situation in the open country; upon 
a clean, porous, and dry soil, with free circulation of air round 
it, but sheltered from the north and east ; raised above the 
plain, with the ground falling from the hospital in all direc- 
tions, so as to facilitate drainage. 

The elevation of a site above the surrounding country is 
very important. Observations taken in Switzerland have 
shown that a milder and more equable climate prevailed at a 
few hundred feet above the valleys than at the bottom, where 
the vegetation of the hillsides would not thrive. 

In the British Isles, during a frost of long duration in 1H79, 
at certain stations on hills, which were 200 and 300 feet above 
the adjacent valleys, the minimum cold registered during the 
winter was 17° Fahr., when in the valleys the absolute cold 
registered as low a minimum as i-i° and 2°. 

The general conclusion shown by these and many other 
observations is, that at a height about equal to that of the 
upper rooms in a high house a more equable and drier climate 
prevails than at lower levels ; drier than at the seaside, and 
with a daily range not much greater, and much less cold on 
the coldest and foggy nights than down below. 

Hence, in ordinary circumstances, delicate persons should 
not sleep on a ground floor ; and living near the top of a high 
house, or on the ridge of a hill, might be of great benefit 
in many cases of lung and throat diseases, and in cases where 
night air has a bad effect. 

But the selection of an elevated site requires care. For 
though elevated positions are generally healthy, yet in cases 
where they are exposed to winds blowing over marshes 
or malarial ground, their very elevation may be a source of 
danger. 



24 Healthy Hospitals. [ch. 

On the other hand, in the case of buildings placed at a 
slight elevation above a marsh, the evil effect of the marsh 
has sometimes been obviated by the interposition of a belt of 
high trees which have shielded the buildings from the influ- 
ence of the wind blowing over it. 

The site selected for a hospital should not receive the 
drainage of any higher ground. 

The supply of water must be ample and good. 

It is an error to build a hospital on a steep slope. No 
doubt, by forming a plateau for the structure, and adopting a 
system of catch-water drainage, the water from the higher 
ground may be more or less cut off from the building ; but 
the higher ground, especially if it be near to the building and 
steep, and if it rise to a considerable height above the hospital, 
will stagnate the air just as a wall stagnates it. Shelter from 
cold, or from unhealthy winds, be it by means of a range of 
hills, or walls, or houses, or trees, should always be at a suffi- 
cient distance to prevent stagnation of air and damp, otherwise 
the shelter from an evil recurring only at intervals may be 
purchased by sacrifice of healthiness at all times. 

The level of water in the subsoil regulates the amount of 
ground air. 

Ground air has a most important influence on the healthi- 
ness of a site. It is desirable to have clear ideas upon this 
subject. 

The air does not cease where the ground begins ; but air 
permeates the ground and occupies every space not filled by 
solid matter or by water. The particles of soil may be com- 
pared to a pile of shot with the interspaces, where the 
circumferences of the shot do not touch, filled with air, or 
which would be filled with water if the ground on which the 
shot are standing were submerged. 

Thus, if you build on a dry, gravelly soil, where the inter- 
stices between the stones are naturally somewhat large, you 
practically build over a large stratum of air. This air moves 



III.] Site. 25 

in and out of the soil in proportion to barometric pressure, 
and with reference to the wind. If there is much water in the 
soil, the air carries with it watery vapours, and is cold, and 
we say such a site is damp. 

There is a considerable quantity of carbonic acid in the 
ground, and there are even considerable variations in the 
amount of carbonic acid present in the soil of localities in 
close proximity to one another ; the amount has been found 
to be doubled in a distance of 50 yards with apparently 
similar soil, probably depending on the organic matter which 
has been present or has percolated into the soil at different 
places. 

The processes going on in the soil at these spots must have 
differed materially ; and if such processes affect health, persons 
inhabiting a building over one of these sites would be exposed 
to different hygienic conditions from persons living over 
the other. 

The fact of this continual free passage of air in and out 
of the ground makes it important that not only should the 
ground we live on be free from water, but more especially 
that it should also be free from impurities. We might just 
as well (indeed probably far better) live over a pigsty, than 
over a site in which refuse has been buried, or in which sewer 
water or other impurities have penetrated, or over a soil filled 
with decaying organic matter. Ground air has been found to 
contain 50 per cent, more carbonic acid than the ground 
water. The level of water in the soil necessarily affects the 
air contained therein : when the level of the water rises, the 
air is forced out ; when it falls, air is drawn in ; but in con- 
nection with this it may be observed that whilst a permanently 
low water level (say 15 feet) in the soil may be healthy, and a 
permanently high water level (say under 5 feet) may be 
less healthy, a fluctuating water level is very unhealthy, 
especially when the fluctuations are rapid. 

The unhealthiness mainly shows itself when the level of the 



26 Healthy Hospitals. [ch. 

ground water falls. This probably occurs from the decay of 
organic matter left by the receding Vv^ater, and from this cause 
apparently fever chiefly occurs in flooded districts when the 
floods have receded. 

Hence it is desirable to keep the permanent level of water 
in the soil, where habitations are placed, as low as possible. 
But where the water cannot be maintained permanently at 
a low level, then keep it at an even level. 

Of course these conditions are modified by considerations 
of geological formation. On clay or on impervious formations 
water either remains to stagnate on the surface, or if the levels 
allow, it passes off the surface rapidly. Porous soils, on 
the other hand, allow of the penetration through them of 
pollution in connection with water to very considerable 
distances. For instance, it may be mentioned that a dis- 
infectant put into the sewers has been known to be traced — 
after no long interval — in wells situated at comparatively 
considerable distances from the sewers. It is obvious that 
the sewers must have been faulty. Water sinks into a sandy 
gravelly soil and thence it drains away when not retained by 
an impervious subsoil. The impurities would not be carried 
into the clay soil, but the sandy or gravelly soil acts as a 
filter to retain the impurities which surface water may bring 
into it, and fever has been observed to stop on passing from 
a sand district to a clay district. Indeed, long-continued 
saturation of porous sandy or gravelly soil in towns by sewage 
or other foul refuse appears to be the cause of much of the 
typhoid fever which cannot be traced to definite causes. 
Sir Charles Cameron has pointed out that in Dublin the 
chances of getting typhoid are 50 per cent, greater on the 
gravel than on the clay, and attributes this to the fact that 
the soil of Dublin has been polluted by a system of storing 
human excreta for centuries, and the enormous accumulation 
of organic matter thus formed is under certain conditions in 
a state to give out into the atmosphere the poison which 



III.] Site. 27 

favours disease. Similar conditions are probably the cause 
of much of the enteric fever in India, and it has long been 
known that whilst in the great cities of America, malaria was 
disappearing with the advance of population, it is being 
replaced by typhoid fever, because the ground has been 
allowed to be saturated for years with organic matter from 
the animal kingdom. Parkes tells us that cholera is un- 
frequent on granite, metamorphic and trap rocks, but a 
careful collation of facts shows that so far as cholera, or 
indeed other zymotic diseases are concerned, the site and the 
geological formation have comparatively little to do with it. 
These diseases occur when there is a population living in a 
filthy condition, where impurities are retained around, on, in 
or under the dwellings — or are allowed to percolate into the 
ground surrounding the dwellings, or into the wells rendering 
the water impure. 

The prevalence of fever in new houses built on the outskirts 
of towns frequently arises from the fact, that the gravel and 
sand which constituted the original soil had been removed, 
the hole thus formed let as a shoot for rubbish, and the 
restored surface converted into a building site ; consequently 
the gradual decay of the refuse evolves emanations which 
pass up into the houses, even through concrete. 

In connection with this it may be instanced that a site 
which has been occupied as a market garden, or which has 
been highly manured, would not be safe for a building site for 
a hospital unless the surface soil were removed to a depth in 
some cases of from one to two feet, or burned. 

The importance of a clean soil is apparent when it is 
remembered that vapour is constantly escaping day and night 
from the soil, especially under grass, and bringing up ground 
impurities with it. This vapour often becomes visible as fog 
in an evening over low-lying meadows, for the same reason 
that fog appears over a river or pond, when after a hot day 
the air cools down at sunset leaving the water warm. 



28 Healthy Hospitals, [ch. 

It follows that the ground surface on which hospital wards 
stand should be covered, both under the buildings and between 
the buildings, by a coating of impervious material, as for 
instance asphalte, or in default of asphalte, cement concrete. 

The temperature of the soil depends on its geological forma- 
tion. Thus if the power of sand to absorb heat be taken at 
100, the power of clay to absorb heat would be represented 
by 66. Moreover, sand radiates heat more slowly than clay. 
Therefore a sandy soil is always warmer than a clay soil. 
Herbage lessens the absorbing power of the soil, and in hot 
climates the oppressive heat of a sandy soil may be tempered 
if the surface be covered with grass. 

The disturbance of soil impregnated with organic matter 
has been a source of danger in tropical and semi-tropical 
climates. Whilst brushwood is a source of danger in hot 
climates, the removal of brushwood by stirring up decaying 
organic matter has caused fever. Digging out foundations, or 
any disturbance of the soil, is almost sure to be followed by 
an outbreak of malarious disease ; the tendency to which 
diminishes or altogether disappears in time as the surface of 
the soil hardens, or undergoes other changes from exposure 
to air. 

The presence of superfluous and stagnant subsoil water in 
the vicinity of a healthy site is dangerous. 

A distinct relation has been shown to prevail between 
phthisis and the level of ground water ; that is to say, the 
lowering of the water level has led to a direct reduction in 
mortality from phthisis. 

But the level of ground water is a condition which it is 
eminently within the power of the engineer to remove by 
drainage of the soil. 

In India, wherever water is applied in excess for irrigation 
so as to become stagnated in the subsoil, there we have ague 
and spleen disease. 

But such localities have been improved by draining away 



III.] Site, 29 

the superfluou55 stagnant subsoil water. To prevent such 
evils, drainage should be combined with irrigation works from 
the beginning. 

These remarks are based upon the assumption, that, in the 
selection of a site, healthiness is the only consideration ; hence 
it will be convenient to summarise here the conclusions to 
which the above considerations point. 

(i) A clay soil is disadvantageous from its cold character, 
but it prevents the percolation of foul matter. 

(2) Ground at the foot of a slope, or in deep valleys, which 
receives drainage from higher levels, predisposes its occupants 
to epidemic diseases. 

(3) High positions exposed to winds blowing over newly 
excavated ground, or over low marshy ground, even when 
miles away, are in certain climates unsafe on account of 
fevers. But the immediate vicinity of a marsh, or other local 
cause of disease, which is separated by a belt of trees from 
the occupied site, may be safer than an elevated and distant 
position to leeward. 

(4) Elevated sites situated on the margin or at the heads 
of steep ravines, up which malaria may be carried by air 
currents flowing upwards from the low country, are apt to 
become unhealthy at particular seasons. Such ravines, more- 
over, from want of care, are often made receptacles for decay- 
ing matter and filth, and become dangerous nuisances. 

(5) Ground covered with rank vegetation, especially in 
tropical climates, is unhealthy, and the presence of such 
vegetation marks the presence of subsoil water. 

(6) In warm climates, muddy sea beaches, or river 
banks, or muddy ground subject to periodical flooding, and 
marsh lands covered alternately by salt and fresh water, are 
peculiarly hazardous to health. 

(7) A porous subsoil, not encumbered with vegetation 
and protected from impurities, with a good fall for drainage, 
not receiving or retaining the water from any higher ground, 



30 Healthy Hospitals. [ch. 

and the prevailing winds blowing over no marshy or unwhole- 
some ground, will, as a general rule, afford the greatest 
amount of protection from disease of which the climate 
admits. 

It follows, from these considerations, that a site selected for 
occupation should be thoroughly under-drained, except pos- 
sibly where the ground is so elevated and porous as to ensure 
that water never remains in it ; and that if there is higher 
ground adjacent, the water from the higher ground shall be 
carefully cut off by underground catch-water drains, and led 
away from the vicinity of the site. 

The object to be attained in laying out the ground is the 
rapid and effectual removal of all water from the buildings 
themselves, and from the ground in their vicinity, so that 
there shall be no stagnation in or near the site. Hence a hard 
compact surface should be secured in the vicinity of buildings. 
It prevents soakage, facilitates sweeping and surface cleanli- 
ness, and diminishes the soil emanations from below. 

It may be stated as a general proposition that the area in 
any country over which fogs appear soonest after nightfall 
should be avoided. 

It has already been mentioned that there are many other 
considerations besides those dependent upon hygiene alone 
which influence the choice of a site for a hospital. 

Amongst these, the necessity of placing the hospital in a 
convenient locality, accessible both to patients and medical 
men, is a very real difficulty, and this often compels the 
erection of a hospital in the midst of a population or in 
unfavourable surroundings. 

In the open country when the site is surrounded only by 
fields, it is of little consequence what is the area of the land 
enclosed in the hospital grounds, except for the purpose of 
preventing encroachment. But in towns the impurity of the 
air of a hospital will diminish in proportion to its distance 
from thickly inhabited places, and under these circumstances 



III.] Site. 31 

an enlarged area ought to be provided to counterbalance the 
unhealthiness of a site. 

In a town, however, the surrounding population often makes 
it either impossible or very expensive to obtain a large site. 
So far this consideration has reference to the maintenance 
of the purity of the air to be breathed by the sick. But 
a certain space for a hospital placed in a town is also 
necessary for isolating the hospital, for the sake of the popu- 
lation living round the hospital. Every sick person is a focus 
from which emanations of more or less injurious kind are 
being thrown off, and the accumulation of numerous cases of 
sickness in one locality adds to the pollution in a rapidly 
increasing ratio. 

Whatever may be the influences which cause the vitiation 
of the air in and around a hospital, whether they be due 
to putrefaction or fermentation and to the development of 
germs, or living organisms, or to consequences entailed by 
such organisms which have not yet been accurately ascer- 
tained, it is abundantly proved that the crowding together 
of individuals on a limited space is favourable to the develop- 
ment of such causes, whilst a large surrounding air-space 
reduces or limits the danger arising from them. 

Consequently it may be taken as certain that a larger free 
space around a building in which sick or injured are located 
is necessary, that is to say in the case of a hospital, than 
would be required in the case of a collection, in a given area, 
of persons in good health. 

In the case of some infectious diseases this has been 
especially apparent. No doubt well-managed fever hospitals 
which stand on an adequate area have not been found to 
involve any appreciable risk to the neighbourhood ; yet even 
with these hospitals the Local Government Board prescribe, 
for London fever hospitals, that no building to which the 
sick would have access should be placed within 40 feet of the 
boundary wall. But in the neighbourhood of small-pox 



32 Healthy Hospitals. [ch* 

hospitals there would appear to be a graduated intensity of 
infection, and it has been shown that the incidence of small- 
pox upon houses within a mile radius of a small-pox hospital, 
apart from any infection due to the conveyance of patients to 
the hospital, was as follows : — The total number of cases under 
review was 2,527. For every 100 houses in the circle of a 
quarter of a mile from the hospital there were i7'35 cases. In 
the ring between a quarter and half a mile, 9'25. In the ring 
between half and three-quarters of a mile, 6* 16. In the ring 
between three-quarters and one mile there were 2'57 cases in 
every 100 houses. 

On this account it has been considered that small-pox 
hospitals are not properly admissible in a populous locality ; 
fortunately small-pox patients may under ordinary circum- 
stances be conveyed some miles by land in well-arranged 
ambulances without much risk, so that in a town it is only 
necessary to provide for a limited number of acute cases, and 
these can be safely treated even among a dense population, 
provided arrangements be made to burn all the air which 
passes out of the ward in which they are placed. 

Some years ago the Surgical Society of Paris appointed 
a committee to consider what should be the minimum area 
of site to be allowed for each sick person in ordinary hospitals. 
The Committee recommended that this minimum area should 
be 50 square metres, or say 60 square yards per patient. 

It must be remembered that the resident population of 
a hospital is much more numerous than that indicated by 
the number of beds, as it includes nurses, servants, staff, 
and resident medical officers. It will probably be found 
not far out of the way to assume that the total resident 
population in a hospital amounts on the average to one- 
half as many again as the patients. 

The proportion of space per patient mentioned above 
means for a hospital of 100 beds nearly i\ acres; 200 beds, 
nearly %\ acres ; 500 beds, rather over 6 acres. 



m.] Site, 33 

These areas, however, are only admissible in cases where 
the obtaining of a larger site is a matter of exceptional 
difficulty, and there are few town hospitals in this country 
which occupy areas as small or smaller than these. 

For instance, the Leeds Hospital, which stands in the centre 
of the town, when originally constructed, occupied about 
3^ acres or 56 yards per bed for 328 patients, instead of 
something over 4 acres, according to the standard above 
mentioned, but in this case the site is surrounded by streets, 
which brought up the area of open space between surrounding 
houses to very much more than the standard of 60 yards per 
bed before mentioned. 

The Marylebone Infirmary affords little over half the above- 
mentioned standard area, viz. under 3a yards per patient ; 
but at the present time there is ground quite open to the 
country on one side. 

The old hospitals of King's College, Middlesex, and Charing 
Cross, cannot be cited as desirable examples of a site. Uni- 
versity College Hospital has had the advantage of the grounds 
of the College opposite to it. 

St. George's Hospital occupies about seven-eighths of an 
acre. On this area it has to accommodate -^^6 patients all 
under one roof, or at the rate of 12 square yards per patient, 
instead of the allowance of 60 square yards per patient recom- 
mended by the Paris Surgical Society; these, with the nurses 
and others living in the building, bring up the resident number 
to a population of 580 per acre, which is a larger popula- 
tion per acre than the most thickly inhabited quarter of 
London. In addition to which there is a medical school 
and a large out-patients' department crowded on to the 
site. 

The site has, however, the benefit of a fine open space on 
three sides, but this advantage is very much diminished by the 
way in which the buildings have been agglomerated, so as to 
prevent the permeation of fresh air to the centre, as well as by 

D 



34 Healthy Hospitals. [ch. 

numerous projections which impede the flow of sunshine and 
fresh air to the wards. 

As a contrast to this hospital we may instance the Johns 
Hopkins Hospital which stands on an elevated site at Balti- 
more. It accommodates 361 patients on 14 acres, with a 
superficial area per bed of about 186 square yards, and every 
building is separate ; there is ample permeation of air and 
sunlight round all the buildings. 

We may also mention the New York Hospital, which was 
built in 1877. It stands on nearly an acre of ground in the 
centre of New York, and accommodates 180 patients, affording 
nearly 30 square yards per bed. It is built with five floors of 
wards. This hospital is, however, arranged to admit light 
and air to every part of the building, in addition to which 
the wards are supplied with carefully devised arrangements 
for artificial ventilation. 

St. Thomas' Hospital was built to accommodate 573 
patients, and the area of the site affords above 70 yards 
per bed, in addition to which the site faces the River Thames, 
which supplies a constant aeration. 

The New Liverpool Hospital affords about 90 yards per 
patient, but there are public streets on three sides, and the 
grounds of the medical school on the fourth side, which 
give additional aeration. 

The Burnley Hospital was arranged to allow no yards 
with 88 beds, and if extended to 132 beds 73 yards, but this 
hospital had an open space on one side. 

The Bradford Hospital, in the centre of the town, with 
i.'if'X beds, affords about 100 yards per bed, and the site is 
surrounded by buildings. 

The Glasgow Western Infirmary, besides being built on an 
open site, affords 154 yards per bed, and the Edinburgh Royal 
Infirmary, also in an open situation, affords 93 yards per bed. 

Of the more recent foreign hospitals, the Antwerp Hospital 
affords about 118 yards, and the Berlin Military Hospital 



III.] Site. 35 

above 135 yards per bed, and the Berlin Civil Hospital 
190 yards per bed. 

The St. Eloi Hospital at Montpelier occupies 22 acres, and 
accommodates 600 patients, or at the rate of nearly 180 yards 
per bed. 

The hospital at Menil Montant (Paris) contains 726 patients 
and occupies a little over 13 acres, affording about 89 square 
yards per bed, but it stands in an open and airy situation 
above Mont Martre. 

The conclusion to be drawn is to obtain as much open 
space round a general hospital as its position will admit of. 

The Infectious Fever Hospitals of London afford the fol- 
lowing areas per patient : — The Eastern Hospital atHomerton, 
98-5 yards ; the North-Western Hospital at Haverstock Hill, 
128 yards; the Western at Fulham, 100 yards; the South- 
western Hospital, 117 yards; and the South-Eastern Hos- 
pital in the Old Kent Road, 115 yards. 

In these hospitals the rule is not to place a sick ward nearer 
than 40 feet from the enclosure wall. 

In fact the minimum space laid down by the Surgical 
Society of Paris has only been acted on in very exceptional 
circumstances, and should be strictly limited to the case of 
small hospitals. 

Good hygienic conditions are comparatively easy to obtain 
even in towns in hospitals of from 150 to 250 beds, but very 
difficult to obtain, especially in large towns, if these numbers 
are exceeded. 

In proportion as the cases of disease are agglomerated 
together, so is the degree of vitiation increased ; hence a 
hospital with few patients may be placed upon a smaller area, 
per patient, than a large hospital ; in other words, the area of 
space occupied by a hospital, per patient, should be increased 
in proportion to the number of patients. 

With a hospital of from 100 to 200 beds, 60 square yards 
per patient might suffice under very exceptional conditions, 

D 2 



36 Healthy Hospitals. 

but with 300 to 400 beds the area should be at least 90 yards 
per patient, and with 500 beds and upwards, 120 to 140 square 
yards per patient would be required. But it may be safely 
laid down that, on a town site surrounded by houses, it is not 
desirable to afford in any hospital less than from 90 to 100 
yards per patient to be accommodated ; or practically a town 
site should not contain more than 50 beds per acre, and for 
fever and infectious hospitals a larger area should be pro- 
vided, and the number per acre should be limited to o^^^ 40, 
or at most 45 beds per acre. 

Hence it would be preferable that in the centre of cities 
hospitals should be erected for urgent cases only; and in any 
case, hospitals in the centre of towns and surrounded by 
dwellings should not be constructed for more than from 300 
to 300 patients each, which would be sufficient for clinical 
purposes. Where large hospitals are built they should be 
installed on open sites in the country, because there the land 
required would be comparatively cheap, and the absence of 
surrounding houses renders the question of area a secondary 
consideration. 

As regards the acquisition of sites for hospitals, it is no 
doubt reasonable that when a new hospital is projected the 
site on which it is to be placed should be a matter of private 
arrangement. But in the case of well-established hospitals, 
which are in efficient action for the public good, and con- 
ducted without any desire of gain, it would certainly appear 
reasonable, where their managers are anxious to enlarge their 
premises with a view of increasing the amount of accommoda- 
tion, or of ameliorating the condition of their patients, that the 
power should be afforded them, under proper restrictions, of 
purchasing compulsorily adjacent land for such purposes. 

The Metropolitan Asylums Board possesses such power 
under a recent Act of Parliament, and there seems to be no 
reason why this should not be extended to other responsible 
hospital authorities in the Metropolis and in other large cities. 



CHAPTER IV. 

CONDITIONS WHICH VITIATE THE AIR IN AN 
OCCUPIED ROOM. 

It will be convenient in the first place to explain briefly 
what are the reasons on the ground of health why a certain 
air-space is wanted, and though in other books this subject 
has been treated at length, it may be convenient here to 
summarise the reasons for change of air. 

Let us first consider how far do we obtain pure air out-of- 
doors. Really pure air is composed as follows, viz. 

Oxygen 209-5 

Nitrogen 7^9' 3 

Other Gases -2 



Parts of Air 1000 

The oxygen is necessary to life, but if it were breathed 
pure, it would burn us away. The nitrogen is an inert gas 
which dilutes the oxygen and prevents it from being injurious 
in the process of breathing. In air out of doors in the open- 
country, there are from 3 to 4 parts of carbonic acid 
gas (CO2) in 10,000 parts of air, indeed it is sometimes as 
low as 2 parts ; this amount will sometimes be increased 
by vegetation, as in a wood, or by the emanations of animals, 
as, for instance, in proximity to a flock of sheep. 

In towns a much larger quantity will sometimes be found. 
Dr. Angus Smith showed an average of 3-8 in the streets in 
London, as compared with 3-0 in the parks, and he found 
that as much as 6-8 per 10,000 parts of air were present 



38 Healthy Hospitals. [ch. 

in confined streets in a fog in Manchester. Dr. Russell has 
found as much as 9, ti, and even 14 parts of CO2 in 10,000 
volumes of air in a dense fog in London. But on the whole 
it has been considered that 4 parts per 10,000 of CO^ in 
outside air may be assumed to be the standard amount. 

Moreover there is always dust in air, i. e. solid particles. 

Dr. Langley has observed the presence of dust in air on 
the tops of the highest mountains. The rain washes the dust 
out of the air ; Dr. Aitken found near his laboratory in 
Glasgow, that whilst during rain, a cubic centimetre of air 
out-of-doors contained 32,000 of these solid particles largely 
inorganic, in dry weather it held 130,000 particles, and in his 
room the air in some parts yielded nearly 6,000,000 particles. 
Professors Carnelley, Haldane, and Bedson have shown that 
the air of a room, in which much movement of persons or of 
articles takes place, exhibits much more dust than that of a 
room which is left for a long time in absolute quiescence. 

This dust consists partly of inorganic matter, and partly of 
minute organisms. The number of organisms^ e. g. bacteria 
and spores found by Dr. Miguel in air from the streets in 
Paris, averaged 3,480 per cubic metre in summer. In the 
vicinity of the Mont Souris Observatory they averaged only 
480, whereas none were found on the top of a high mountain 
in the Alps. In winter the numbers found were much less 
than in summer. In the open country in summer the dust in 
the air consists largely of pollen. 

This dust affords nuclei upon which the aqueous vapour in 
the air can settle, and this forms haze and fogs, and when the 
particles are over-loaded with moisture they fall down as rain. 

Near the sea, where the inorganic dust contains saline 
particles, or in towns where it contains ammonia, its affinity 
for moisture is greater, and fogs are more prevalent ; and 
where smoke from our coal fires is added, the tarry matter 
renders the fogs more persistent, and the sulphurous acid 
makes them more unpleasant. 



IV.] Conditions which Vitiate the Air, etc. 39 

When a person is in an open space out-of-doors, the 
air is perpetually flowing past him. It has been estimated 
that the air of the atmosphere moves at a rate of rarely less 
than from 5 to 7 miles per hour ; the former is equivalent to 
7 feet per second, but the average movement is from 20 to 
24 feet per second. Now 24 feet per second means 17 miles 
per hour; but let us consider what the effect will be of a move- 
ment of only 7 miles an hour, or 10 feet per second. Imagine 
a frame about the height and width of a human body in the 
open air: that is to say, about 6 feet high by i^ foot wide, 
occupying an area of 9 feet. If this be multiplied by 10 feet 
per second for the velocity of air, it will give as the quantity 
of air which will pass over an individual in one second 90 cubic 
feet, in one minute 54°° cubic feet, and in one hour 324,000 
cubic feet. 

Even out-of-doors the effect of congregating large numbers 
of persons together may prevent the free access of fresh air to 
those in the middle of a crowd. As an instance of this, it has 
happened that on a still day, persons in the middle of a 
crowd have fainted for want of air. But in an occupied room 
the respiration of individuals, their perspiration, the burning 
of candles, emanations from food and all such matters, vitiate 
the air of rooms at a certain rate. 

Every human being, in order to live, must be constantly 
breathing ; in the act of breathing he takes in oxygen, and 
throws out from his lungs carbonic acid (CO,) ; but he also 
throws off a large amount of watery vapour, organic matter 
and ammonia. This organic matter consists of epithelium, 
and molecular and cellular matter. 

In addition to this matter from the lungs, portions of 
epithelium are constantly being given off from the skin. In 
hospitals there are sometimes pus cells in the air, which are 
given off from suppurating surfaces, 

A large amount of watery vapour is also given off from the 
skin. 



40 Healthy Hospitals. [ch. 

The amount of watery vapour varies ; but taking the 
amount given off by an individual in ordinary health from 
the skin and lungs together, it is enough to saturate about 
90 cubic feet of air per hour, at a temperature of 6'^ Fahr. 

This watery vapour is full of the organic matter which is 
thrown off from the body. With persons suffering from 
disease, especially infectious fevers, or from wounds or sores, 
these emanations, as well as those from the lungs in the 
case of phthisis, are greater in quantity, and it is generally 
assumed more poisonous in quality, than from persons in 
health. 

Hence it may be assumed that vitiation occurring in the 
air of occupied rooms may arise — 

(1) From products of normal respiration and perspiration; 

(2) From products of disease, want of cleanliness, or 
other abnormal conditions of the persons present in the 
rooms ; 

(3) From impurities arising from the floor, walls, &c. 
of the room itself. 

As a rule the proportion of carbonic acid present in the air 
is taken as a sufficient index of vitiation. But air which, 
judged by the carbonic acid standard, is sufficiently pure, 
might be exceedingly impure when judged by the number of 
micro-organisms present in it, and vice versa. The carbonic 
acid and micro-organisms have different sources. The amount 
of the former depends on the number of persons or lights 
burning in the rooms as compared with the means of ven- 
tilation — that of the latter being determined chiefly by the 
conditions of the room itself and its occupants as regards 
cleanliness, &c. 

The immediate dangers from breathing air highly vitiated 
by respiration appear to arise mainly from the excess of 
carbonic acid and deficiency of oxygen. 

But the actual quantity of air impaired each minute by 
any one individual in a state of comparative rest is really 



IV.] Conditions which Vitiate the Air, etc. 41 

small. About i of a cubic foot of air is vitiated by breathing 
(inhaled and exhaled) in the one minute's time, and even 
this is not entirely spent for use over again. To this must 
be added the quantity of air vitiated by transpiration, from 
the person, of moisture laden with organic matter. 

Ventilation would probably be perfect, if there could be 
removed, without admixture of other air, the volume of air 
exhaled in breathing, together with a layer of air next the 
person, and the two volumes were taken to be one cubic foot 
of air per person per minute, while at the same time there 
should be furnished the same quantity, to answer the double 
purpose of supplying fresh air for inhalation, and a new 
' atmosphere ' next the person. 

But as we cannot in practice thus catch emanations from 
each person, they mix with the surrounding pure air, and our 
only remedy is to dilute this mixture with an adequate volume 
of outside air, so as to bring the whole to some accepted 
standard of impurity. 

The measure of impurity of air in an occupied room has 
been till recently always taken from the excess of CO2 in the 
occupied room over that out-of-doors, and from Professor 
Haldane's recent experiments, this would appear to be a safe 
standard to rely upon. 

The estimates of sanitarians as to the amount of air re- 
quired are generally based upon the observations of De 
Chaumont, Parkes, and others, as to the amount needed to 
keep an occupied room free from perceptible odour to a person 
entering it from the outer air, and on the percentage of car- 
bonic acid which is found in the air of rooms in which this 
animal odour is barely perceptible. 

When, as a product of respiration, the proportion of carbonic 
acid in a room is increased from the normal ratio of between 
3 and 4 parts in 10,000 to between 6 and 7 parts in 10,000, 
a faint, musty odour is usually perceptible. Assuming that 
the air of an inhabited room should be just so impure as to 



42 



Healthy Hospitals. 



fCH. 



possess this odour, the following table by Parkes shows the 
amount of air necessary to dilute to this standard : — 



Amount of cubic 

space (breathing 

space) for one man 

in cubic feet. 


Ratio per 1,000 of 
carbonic acid ftom 
respiration at the 
end of one hour if 
there has been no 
change of air. 


Cubic feet of air 
necessary to dilute 
to standard of -2, or 
including the initial 
carbonic acid, of -6 
per 1,000 vols, during 
the first hour. 


Cubic feet of air 
necessary to dilute 
to the given standard 

every hour after 
the first. 


lOO 


6-00 


2,900 


3,000 


200 


3.00 


2,800 


3,000 


300 


2.00 


2,700 


3,000 


400 


1.50 


2,600 


3,000 


500 


1.20 


2,500 


3,000 


600 


1. 00 


2,400 


3,000 


700 


0.85 


2,300 


3,000 


800 


0.75 


2,200 


3,000 


900 


0.66 


2,100 


3,000 


1000 


0.60 


2,000 


3,000 



The above table refers to rooms occupied for a number of 
hours consecutively. 

Dr. de Chaumont's experiments were made in barracks and 
in hospitals, and a result comes out from them confirmatory 
of the opinion that, in the case of sick men, more air is 
required to keep the air-space pure to the senses than is 
necessary in the case of men in health. Thus, in barracks, the 
mean amount of respiratory carbonic acid, when the air was 
pure to the senses, was -196 per 1,000 volumes, but in hospitals 
it was only -157 ; or, in other words, whilst in the hospitals 
the air would have smelt somewhat impure when the CO2 
was -196, in the barracks with that amount it was fresh. 

Surgeon-General Billings, of the U. S. Army, gives a com- 
paratively simple method of testing for CO2 in breathed air 
in the appended foot-note ^. 

^ For ordinary purposes a conve- of carbonic acid is the following, 
nient method of testing the amount for which there will be needed six 



IV.] Conditions which Vitiate the Air, etc. 43 

Various methods have been used for measuring the organic 
matter in air. Dr. Angus Smith devised two methods. 

According to the first of these methods, a definite quantity 
of the air to be examined is slowly bubbled through a dilute 
solution of potassium permanganate of known strength, until 
it is fully or considerably bleached, and the amount of unde- 
composed permanganate determined by oxalic acid. 

In the second method a known volume of air is bubbled 
through distilled water, and the latter examined for free and 
albuminoid ammonia by Wanklyn and Chapman's process for 
water analysis. 

These methods are, however, inapplicable in circumstances 
and in places where such determinations are most desirable, 
chiefly on the score of time and of the extent and compli- 
cation of the apparatus required. 

Moreover, very considerable variations in the organic 
matter are sometimes liable to occur within the period of 
determination required by Dr. Angus Smith's method. 

well-stoppered bottles, containing 10,000. If no turbidity appears, 
respectively 450, 350, 300,250, 200, treat the next sized bottle, viz. of 
and 100 cubic centimetres, a glass 200 cubic centimetres, in like man- 
tube or pipette graduated, to con- ner. Turbidity in this would indi- 
tain exactly 15 cubic centimetres to cate 12 parts in 10,000. If this 
a given mark, and a bottle of per- remains clear, but turbidity is pro- 
fectly clear and transparent fresh duced in the 250 cubic centimetre 
lime-water. The bottles must be bottle, it makes about 10 in 10,000. 
perfectly clean and dry. Having The 300 cubic centimetre bottle 
made sure that they are filled with indicates 8 parts, the 350, 7 parts, 
the atmosphere which is to be ex- and the 450 less than 6 parts. To 
amined, which can best be done by judge of the turbidity, mark a small 
pumping into them a quantity of piece of paper on the inside with 
this air by means of one of the a cross in lead pencil, and gum to 
small handball syringes, which may the side of the bottle on the lower 
be procured in any drug store, and part. When the water becomes tur- 
taking care that none of your own bid the cross will become invisible 
breath is pumped in, add to the when looked at through the water, 
smallest bottle by means of the Thiswill enable one to judge roughly 
pipette 15 cubic centimetres of the of the amount of carbonic acid in 
lime-water, put in the cork, and the air. For more accurate analysis, 
shake the bottle. If turbidity ap- the method of Pettenkofer, as de- 
pears, the amount of the carbonic scribed by Parkes, should be em- 
acid will be at least 16 parts in ployed. 



44 Healthy Hospitals, [ch. 

A modification of Dr. Angus Smith's plan has been adopted 
by Dr. Carnelley, that is to measure the volume of oxygen 
required to oxidise the organic matter in a definite number of 
volumes of air by the reduction of potassium permanganate \ 

This method, however, does not give absolute, but only 
relative results. The general conclusions, however, which 
Dr. Carnelley obtained from a number of experiments are 
deserving of notice here : — 

(i) As regards outside air, the quantity of organic matter 
varies considerably, within certain limits, from day to day, and 
from hour to hour on the same day. 

Variations from day to day are subject to the conditions of 
the weather. It has been found somewhat less immediately 
after or during rain or snow. The highest results of all were 
obtained on foggy nights, e.g. 15-7, 17-0 volumes of oxygen 
were required to oxidise 1,000,000 volumes of air. High 
results were also obtained during a slight drizzling rain, 
accompanied by mist. 

(a) A close connexion is observed between the amount of 
organic matter present in air and the combustion of coal. 
The organic matter is lowest in the middle of the night, rather 
higher in the morning, and considerably higher in the middle 
of the day, and higher still towards evening, after which it 
decreases. 

On comparing the averages of a large number of cases it 
appears that a high carbonic acid is accompanied by a high 
organic matter, and vice versa. 

But whilst the carbonic acid seldom passes beyond the 
limits of 2 to 6 volumes per 10,000, the organic matter varies 

^ There are some objections to matters in the air, besides the or- 

this method ; for instance — ' it does ganic matter, such as sulphuretted 

not directly estimate the organic hydrogen, nitrous acid, sulphurous 

matter, but only measures the acid, &c. Moreover the organic 

amount of oxygen required to oxi- matter in air is of various kinds, 

dise either the whole, or more pro- and consequently the permanganate 

bably only a portion of it ; and the will most probably be selective in 

permanganate acts upon various its action.' 



IV.] Conditions which Vitiate the Air, etc. 45 

from a quantity too small to estimate to as much as will 
require for oxidation about 16 volumes of oxygen per 1,000,000 
volumes of air. 

The organic matter in air is most probably partly solid and 
partly gaseous ; the solid — obeying a different law to that of 
diffusion — slowly settles down, whilst the gaseous part, unlike 
carbonic acid, is most likely an unstable compound or com- 
pounds, and readily undergoes oxidation. 

An atmosphere which has been entirely at rest for some 
time is found to contain less organic matter than it did 
previously. This is not necessarily entirely due to the settling 
down of the solid organic dust, but is probably due in part to 
oxidation. 

It may, however, be assumed that the quantity of CO2 in 
breathed air will within limits, on the average, afford under 
ordinary circumstances a fair test of the quantity of organic 
matter present. 

An index of the degree of impurity in the air in occupied 
rooms has been sought in the presence of those minute 
organisms which have been recently brought into prominent 
notice by the increased attention given to the study of 
bacteriology. But our knowledge of this science and of the 
nature of organisms is too recent to allow us to lay down 
any fixed rules for judging of what are the dangerous 
characteristics of air in wards measured by this standard. 

In addition to this, there is a further difficulty with such 
a test. The dust and the number of organisms present in the 
air of any room may be enormously increased at any moment 
by movement of persons or materials in the room. The 
shaking of a counterpane, the movement of a nurse or of 
a patient, might seriously change the conditions exhibited by 
this method of test. Moreover, any test for impurity in the 
air of a sick ward should be such as can be made without 
undue delay, and the time required for the cultivation of the 
organisms present in the air would prevent this method of 



46 Healthy Hospitals. 

testing air from being available, except for special objects and 
enquiries. 

In considering the vitiation of the air in its relation to 
ventilation^ it has to be remembered that the emanations from 
the bodies of patients do not diffuse themselves so rapidly or 
uniformly as, under ordinary circumstances, is the case with 
carbonic acid. They hang about as the smoke of tobacco 
may be said to do, in corners and places where there are 
obstructions to the movement of the air. For instance, in 
some experiments made upon the air of a well-ventilated 
ward, it was found that whilst there were 5*8 volumes of CO^ 
per 10,000 volumes of air near the patients, and 8-5 volumes 
in the centre of the ward, the volumes of oxygen required to 
bleach the organic matter in 1,000,000 volumes of air was 
fifteen times as much, near the patient's bed, as it was in the 
centre of the ward. 

This may probably be accounted for by the fact that any 
movement, as^ for instance, of the bedclothes of a patient, 
would largely add to the organic dust in the vicinity. 



CHAPTER V. 

QUANTITY OF AIR NECESSARY TO MITIGATE THESE 
CONDITIONS. 

If the condition of the air throughout the ward were 
uniform, ventilation would be comparatively simple, and 
whatever were the amount of the floor-space or cubic space, 
the whole air would attain a permanent degree of purity, or 
rather impurity, theoretically dependent upon the rate at 
which emanations are produced and the rate at which fresh 
air is admitted, and the question of space between the patients 
would be of less importance. That is to say the same supply 
of air will equally ventilate any space^ or which is the same 
thing, the same supply of air is required for a small space 
as for a large space. Hence the question of what should 
be the minimum cubic space depends upon the following 
considerations : — 

(i) An adequate floor-space. 

(2) A change of atmosphere frequent enough for health, 
but not so frequent as to cause draughts. 

(3) Sui^cient space to reduce to a comparatively small 
amount the danger from temporarily impeded ventilation. 

(1) Adequate floor-space. The floor-space is the im- 
portant element of the cubic space ; whilst it is undesirable 
that any ward should be less than 12 feet high, it has been 
generally assumed that, in hospitals, the height above 12 feet 
may be left out of consideration in calculating cubic space ;^ 



48 Healthy Hospitals. [ch. 

but this cannot be accepted as an axiom because, with a very 
long or wide ward, the height forms an important element 
(1) in the movement of the currents of air, (2) in the pene- 
tration of daylight ; and whilst we may accept a height of 
12 feet for a barrack room or ward of 20 to 22 feet wide, the 
due movement of the air in wards of 26, 28 and 30 feet require 
heights of 13 feet, 14 and 15 feet, and with greater widths 16 
feet. Exclusive of the question of the due aeration of the 
space occupied by the patient, the floor space must suffice for — 
{a) Adequate space between sides of beds, to admit of 

all necessary operations of nursing. 
{h) Adequate width at foot of bed for furniture, and easy 

movement about the ward. 
{c) Adequate space for students, when there is a Medical 
School. 

The distance between beds at a low computation should 
not be less than from 4 feet 6 inches to 5 feet ; this, with a 
three-foot bed, would afford a lineal bed-space of from 7 feet 
6 inches to 8 feet : assuming the foot of the bed to be 7 feet 
from the wall, each bed-space should extend 6 feet at 
least beyond the bed ; thus each bed would occupy a space 
of 8 feet X 13 feet, or 104 square feet of area, which would 
afford 1,300 cubic feet, with a ward 12 feet 6 inches high; 
1,350 cubic feet with a ward 13 feet high ; and 1,450 cubic feet 
with a ward 14 feet high. 

Of course this floor-space would be a minimum and must 
be increased if there is a Medical School, or in the case 
of an excess of emanations from the patients, wherever the 
ventilation does not adequately remove such emanations. 

But it must be remembered that any increase to the floor or 
cubic space beyond what is actually required causes unneces- 
sary outlay in first construction, and entails a continuing 
excess in the charges for warming and service. And it may 
be assumed as an axiom that, without unduly depreciating 
the beneficial effect of abundant air-space, the frequency with 



v.] 



Quantity of Air Necessary, etc. 



49 



which, and the manner in which, the air is changed, is a far 
more important point to be attended to in providing a purer 
atmosphere, than floor space or cubic space. 

(2) A change of atmosphere frequent enough for health, 
but not so frequent as to cause draught. And — 

(3) Sufficient space to diminish danger from impeded 
ventilation. 

Let us first consider the effect of arrested ventilation. Let 
us suppose two occupied spaces, one of 500, and the other of 
J 000 cubic feet, ventilated so that the ratio of carbonic acid 
is -06 per cent., and that from some cause or other the 
ventilation is arrested in both, the condition will then be as 
follows : — 

Ratio of Impurity, calculated fro7n Prof. DottkirCs formula. 







1000 ft. 


CO2. 


Soo ft. CO2. 


After I 


hour 


. -12 per 


cent. 


. .18 per cent 


>, 2 


hours . 


• -18 „ 




. -30 „ „ 


» 3 


>) 


• -24 » 




. .42 „ „ 


» 4 


)) • 


• -30 » 




. -54 „ » 


„ 6 


)) 


. .42 „ 




. -78 „ „ 


„ 7 


>j 


• -48 „ 




• -9° „ „ 



There is difference of opinion as to the amount of carbonic 
acid that can be borne, but when conjoined with fetid organic 
matter, as in the products of respiration, it is pretty generally 
agreed that -3 per cent, can hardly be supported, and that at 
•5 per cent, the atmosphere is unendurable. 

From the foregoing table it will be seen that -3 per cent, is 
reached in the case of 500 feet in two hours, but in the case 
of 1,000 feet in four hours, whilst '5 per cent, would be 
reached in the former case in about three and a half hours, 
in the latter not until seven hours had elapsed. 

The change of atmosphere frequent enough for health 
depends upon the observance of certain conditions of temper- 
ature and humidity, as well as upon the amount of impurity 
from CO2 in occupied rooms. 

£ 



50 Healthy Hospitals. [ch. 

On this account the atmospheric conditions of the country 
in which the hospital is to be placed have to be studied. 

The comfortable warmth of air indoors is given by various 
authorities, as follows : — 

Peclet, 'Traite de la Chaleur,' gives 59° Fahr. Morin, 
■ Etudes sur la Ventilation,' for nurseries, schools, &c. 59° 
Fahr., hospitals 61° to 64° Fahr. Tredgold, ' Principles of 
Warming and Ventilating,' &c., 56° to 62^ Fahr. Reed, 
' Illustrations of the Theory and Practice of Ventilation,' 65° 
Fahr. De Chaumont, 62° to 65° Fahr. for hospitals. These 
apply to this country, and to France ; whilst in the United 
States Surgeon-General Billings lays it down that the tem- 
perature of 68° to 70° Fahr. is necessary. 

Comfort, if not existence, depends upon a constant loss of 
heat from the person. The internal natural warmth of the 
body is about 98-6° Fahr., and this is independent of the heat 
of the external air, and is maintained by the food we eat 
and the oxygen we breathe ; the personal comfort which 
arises from the temperature and humid condition of the air 
proceeds from the cooling effects which must go on with 
constancy and regularity, and yet not so fast as to produce 
the sensation of cold. The origin of the natural heat is well 
established. There is inhaled by each adult in comparatively 
still life, each three to four seconds, from 30 to 40 cubic inches 
of air, under such atmospheric conditions as may exist at the 
place. Thus there may be extreme differences of temperature 
ranging from —40° to + 140° Fahr., as well as extremely 
variable proportions of humidity, from the point of saturation 
on the one hand to that of nearly an anhydrous air on the 
other. A portion of the oxygen of the inhaled air is con- 
sumed in the system ; and the exhalation which follows each 
inhalation, emits about 4 per cent, of carbonic acid, and i\ 
per cent, of vapour of water. Two or three grains of carbon 
are consumed in the system each minute, giving out 3I to 5| 
units of heat ; the unit of heat being the equivalent of a 



v.] Quantity of Air Necessary, etc. 5 1 

pound of water heated 1° Fahr. It is the dispersion of this 
heat which establishes the sensation of comfort. 

The deprivation of heat from the person is more due to 
evaporation from the lungs or throat, and from the skin, than 
from heat lost by conduction to the surrounding air or dis- 
persed by radiation to adjacent objects. Thus the inhalation 
of cold vapour from fog may cause much discomfort from 
the rapid absorption of heat which it induces. And the 
hygrometric state of the air has so much effect in inducing 
or retarding evaporation, as to make ^6° Fahr. in the west 
and south of England, in Ireland and in Normandy, sensibly 
as warm as 80° in Canada or Minnesota at the same season. 

As regards Tempei'atiire, it may be assumed for hospitals 
that the dry-bulb thermometer ought to read 63° Fahr. to 6^ 
Fahr., and should not if possible go much below 60° Fahr. 

The wet-bulb ought to read 58° Fahr. to 61° Fahr. In any 
case the difference between the two thermometers should not 
be less than 4° Fahr. or more than 8° Fahr. In the open air 
in healthy weather it is often 8° or 9°. 

The difference is of course increased in hot and dry climates. 
Vapour ought not to exceed 4-7 grains per cubic foot at a tem- 
perature of 6'^, or 5-0 grains at a temperature of 6^ Fahr. 

The limit of humidity which can be permitted in hospitals 
in this country is ']^ per cent, of total saturation or under. 

When the outer air is saturated, as in wet weather, the 
reduction of the humidity in a room will depend on the 
increase of temperature of the air admitted. 

The capacity of the air for moisture increases enormously 
with the temperature, and that which would saturate air at 
50° Fahr. would give about 70 per cent, at 60° Fahr. Thus, 
at 50° Fahr. a cubic foot of air is saturated by 4-1 grains ; but 
at 60° Fahr. it requires 5-8 grains, so that 4-1 grains would 
give us only 71 per cent. 

The table on the next page shows the proportion of 
moisture required to saturate air at different temperatures : — 

E il 



■52 



Healthy Hospitals. 



[CH. 






< 

O 



< 



'S 






>^ 



3 


CJ 


O 


^ 


rt 


U-i 


> 


O 




m 


Tt 


(U 


fi 


j:^ 


cti 


u 



OS 
6* 



<u 


o 


rrt 


)_ 


^H 


0) 


3 


-r) 


C/2 


a, 

en 
O 




r^ 




-l-i 
< 






rt 


C 



O 


(U 




^ 


u, 


■*-> 


3 


u. 


O 


dj 


a, 


x) 


rt 


r- 



> 



.Jh W 



a, 
S 

(U 



^ a °T3 rt u S 
u rt g c t. ^^ 



ro >-i i-H 



u^ OS O 

1-1 00 MD 



Weight of 
Dry Air 

mixed with 
one pound of 

Vapour in 
pounds. 

lO 




^ 


t^ 


ON 


'^ 


i-O 


OO 


LO 


g 


^ 


GO 




t^ 


liH 


ro 


OS 


^ 


O 


N 


ro 


M 


•rf 


OS 


N 


l_i 


^ 




ON 


srs 


M 


OO 


LO 


'^f 


N 






o 


N 


(— t 














^- -S-a 


















d) 


5s'M:hl _ 


N 


OS 


OS 


ON 


O 


M 


r^ 


LO 




ON 


t^ 




r^ 


00 


SO 


'^ 


SO 


el 


Weig 

Vap 

mixec 

one p 

of A 

pou 


o 


ro 


00 




so 


ro 


u-l 


''t 


Q 


n 


O 


hH 


h-t 


cs 


rj- 


M 


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q 


q 


q 


q 


q 


q 


CJ 




of„H§ " 


ON 


Tf 


t^ 


^ 


^ 


r^ 


t-^ 


SO 


o 


^ 


t^ 


() 


M 


00 


c^ 


sr:) 


OS 




N 


d 


m 


lY^ 


N 


"^ 


OS 


N 


OO 


'^ 


00 


.2 


so 


o 


r^ 


u^ 


m 


01 


OO 


OO 


so 


t^'S 2 2 


CO 


00 


t^ 


t^ 


r-N 


t^ 


so 


LO 


fT 




IS" 


O 


o 


q 


q 


q 


q 


q 


q 


q 










































^ s 


^ 




















° ri 


o 0-3 

3 .. ft. 


ON 


Tl- 


r^ 


1— ( 


^_< 


r^ 


r^ 


so 


o 


R> 


l^ 


o 


N 


00 


N 


so 


CJN 




<s 




CO 




OO 


M 


so 


OS 


t-^ 


OO 


IJ 


o 


n 


o 








N 


o 


so 


Q 


n 


o 


o 


O 


() 


() 


hH 


f<^ 


^^.s 


o 


q 


q 


q 


q 


q 


q 


q 


q 


«.^ 










































Uw 






















O 


"^ ^ . 




















J2 


■I<l ^ 


to 


N 


sn 


t^ 


r^ 


so 


OS 


t^ 


o 


SO 


n 


sn 


^ 


M 


O 


i-r> 


t^ 


o 




CO 


OO 


t-^ 


t^ 


t^ 


t^ 


SO 


'^ 


o 


If- 


O 


q 


q 


q 


q 


q 


q 


q 


• 










































for 
Air 
IX tu 
r an 
ur i 
sof 
ury 


t~^ 


n 


ro 


vr% 


so 


OS 


vo 


M 


o 


t^ 


^ 


fO 


so 


ro 


N 


00 


ON 


o 


lastic 
f the 
heM 
of Ai 
Vapo 
inche 
Merc 


GO 


t^ 


"-1 


CO 


i-i 


oo 


00 


ON 


o 


ON 


^^ 


OS 


ON 


ON 


CO 


t^ 


1— f 


o 


M 


cs 


M 


N 


N 


N 


« 


M 




W o* 























s ti 



•3 S'-g S w 



Tl- w CO so 



M so O M 



u- 4j rt t; ti c • 

bo o j>,it: g 5 o 



f^ Os i-i 

O ^ ON 

t^ SO LO 

O O O 



-r hS ft. a, o " 



LO O M M M N fO 
ro Q Tl" SO CO O Tj- 
On O O O O "-I 1-1 



v.] Quantity of Air Necessary, etc. 53 

The diagram (Fig, i on page 54) shows the increase in the 
capacity of the air for carrying off moisture, as the temperature 
of the air rises. The curved lines represent 10, 20, &c. to 100 
percent, humidity; 100 per cent, being the dew point. The 
horizontal line of figures from 10 to 200, at the top of the 
diagram, indicate the grains of moisture per cubic foot of air, 
while the temperature of the air is given in degrees Fahr, at 
the left side. If therefore the outer air is at a temperature of 
50°^ and if the temperature inside the room be maintained at 
a comfortable standard, say 6'^ to 6^, the incoming moisture 
due to the condition of the outer air would never cause an 
excess of humidity. 

In the case of an external atmosphere saturated at or above 
the temperature in the room, such as occurs occasionally in 
hot climates, it would be necessary to let in an unlimited 
quantity of air through every possible aperture. 

The volume of air which should be provided in a room 
to maintain the atmosphere at a proper degree of humidity, 
depends upon the sources of vapour inside the room. Every 
man gives off from lungs and skin each hour enough to raise 
the humidity from 70 per cent, to complete saturation in 500 
cubic feet at 60° Fahr., and to raise it to 82 per cent, in 1500 
cubic feet. Now to reduce this amount to ']'^ per cent, 
would take 3,000 cubic feet of air saturated at 50° Fahr,, or 
2,000 at 98 per cent. But the vapour given off by the body 
is not the only source of humidity. Humidity may arise 
from the combustion of lights. 

For instance, a gaslight affording i candle power of light, 
that is to say giving an amount of light equal to a sperm 
candle burning 1 20 grains per hour, will emit -025 lbs. of 
watery vapour, A sperm candle would for the same amount 
of light give out -02 lbs. of watery vapour, and an oil lamp 
•018 lbs. Thus we shall not be far wrong in considering the 
effect on the air of each gas or candle light burned in the 
room as equivalent to that of a human body. 



54 



Healthy Hospitals. 



[CH. 




M 

E 



}!at4U9j(iivj sa9jSsQ 



v.] Quantity of Air Necessary, etc. 55 

The humidity will moreover be affected by the vapour of 
liquids used in the room. 

Upon this theoretical assumption it would appear that with 
an initial air-space of 1000 cubic feet occupied by one indi- 
vidual it would be necessary to supply 3000 cubic feet, per 
hour, to maintain the room in a proper condition of humidity. 

As regards other impurities, if 0-2 per 1000 of CO2 is 
accepted as the limit of respiratory impurity in a well- 
ventilated air-space, in addition to the 0-4 per 1000 in 
normal air, we can calculate the amount of air necessary 
for the purpose. For this, it is more convenient to state the 
ratio of COg per cubic foot, so that o-3 per 1000 would be 
0-0002 per cubic foot, and calling this M, the amount of CO2 
given out by a single individual C, and the delivery of air 

required ;ir, we have : 

_C_ 

^~ J/' 

Now, when C = o-6, and M = 0-0002, we have the following : 

0.6 

0-0003 ^ 

Or, it requires 3000 cubic feet per hour to preserve the air-space 
in the required state of limited impurity. Upon these assump- 
tions the theoretical calculations, based first upon humidity 
and secondly on carbonic acid, bring us to similar conclusions 
in each case. In connexion with this it is desirable to 
mention that experiments made in barracks showed that 
a much less amount of air, per head, delivered through 
ventilators kept the air of the room in a satisfactory con- 
dition as tested by the sense of smell ; and this was attributed, 
partly, to the badly fitting doors and windows, and partly to 
porosity of walls. 

The barrack-room walls were generally of brick, lime-whited 
without plaster. 

The volume of air which will flow through ordinary brick 
walls and plaster is very great. 



56 



Healthy Hospitals. 



[CH. 



The experiments of Shultze and Marker, and of C. Lang 
of Munich, showed that with a brick wall of ordinary thick- 
ness, and a difference of temperature of o^^ between that of the 
room and the outside air, very nearly lo cubic feet of air 
passed through each square foot of wall surface, but the mortar 
in the walls was nearly equal to one-sixth of the cubic content 
of the wall. A wall of mud and plaster allowed a passage of 
] 8 cubic feet of air, per hour, per square foot of wall, with a 
difference of temperature of 20° inside the room as compared 
with that outside. 

These amounts would show that in the case of a closed 
barrack room or hospital ward at night, with a high inside 
temperature as compared with the temperature outside, 300 
or 400 cubic feet, per occupant, per hour, might easily pass in 
through brick and plaster walls. 

But the porosity of a material is more fully shown by its 
power to absorb water. The following is the percentage of 
its own weight of water which each of the materials mentioned 
below has been found to absorb : — 



Bricks. 


per cent. 


Stones. 


aer cent. 


Malm cutters 


. 22 


Good granite 


•5 


Malm bright stock . 


. 22 


Bad specimen granite 


3 


Brown paviors . 


• 17 


Sandstone — 




Hard paviors 


. 9.5 ■ 


Craigleith 


8 


Common grey stock . 


. 10.5 


Mansfield 


10.4 


Hard „ „ . 


• 7-5 


Hassock (very bad quality) 20 


Staffordshire — 




Limestone — 




Common blue 


. 6.5 


Portland 


13-5 


Brown glazed brick . 


. 8.6 


Ancaster 


16.6 






Bath 


17 






Chilmark 


8.6 






Kent rag 


1-75 






Ransome artificial stone 


12 



v.] 



Quantity of Air Necessary, etc. 



57 



From this it appears that walls of any of these materials, 
being always more or less porous, must admit of a continuous 
spontaneous change of air when dry. 

An experiment made in New York, by Mr. Putman, as 
detailed in the note^, showed that with every means taken 
to prevent porosity or cracks, the inflow through walls amounted 
to nearly 5,400 cubic feet per hour, in a room containing only 
a little over 3,000 cubic feet of air space, when the outside air 
was about 2fi° Fahr,, and that inside varied from 72° to above 
90° Fahr. 

These facts may help to explain some matters connected 
with the healthiness of improvised hospitals. But with the 
modern system of ward walls lined with either highly glazed 



^ Experiments on porosity of 
walls to air in an ordinary living 
room, by Mr. Putman of New York. 

The room was about 5 metres 
square and 3-6 metres high, having 
5 windows, 2 doors, and a fire-place, 
with plastered walls and ceiling, and 
a soft pine floor. 

A flue 10 metres long, from a base- 
ment furnace, furnished the rooms 
with hot air. The windows and 
doors were first made as tight as 
possible with rubber moldings. The 
fire-place was then closed by draw- 
ing the damper and pasting paper 
over the cracks. The brick back 
and jambs were oiled to render them 
impervious. All the woodwork was 
thoroughly oiled and shellacked. A 
good fire was lighted in the furnace, 
and the register opened into the 
room, all doors and windows being 
closed and locked, and the key- 
holes stopped up. The hot air 
entered almost as rapidly with the 
doors closed as when they stood 
open, and it continued to enter at 
the rate of 2-5 cubic metres per 
minute without diminution as long 
as the experiment was continued. 



The thermometer stood at 2° C. 
outside. The entering hot air ranged 
from 40° to 55° C. The day was 
March 3, 1880. The pressure of 
the hot air from the register was suffi- 
cient only to raise a single piece of 
cardboard from the register. On 
the 5th March a coat of oil paint 
was applied to the walls and ceil- 
ings. This diminished the escape 
of air only about 5 per cent. On 
the 19th March four coats of oil 
paint had been put on the walls 
and ceilings, and three coats on the 
floor, to render them absolutely im- 
pervious to air. The escape of air 
was diminished only about 10 per 
cent. On the 25th March all the 
window sashes were carefully ex- 
amined, and all visible cracks at the 
joints, at the pulleys, cord fastenings, 
&c., carefully caulked and puttied. 
The result of all this was a dimi- 
nution at the utmost of but 20 per 
cent, in the entrance of air through 
a register. Each experiment was 
continued during more than an 
hour. The air entered as freely at 
the end as at the beginning of the 
hour. 



58 Healthy Hospitals. [ch. 

bricks with cement joints, or with polished Parian cement, 
very Httle change of air can take place through the walls. 

In a warm climate the natural changes of temperature, and 
consequent alteration of the conditions which govern the 
movement of air, differ widely from those in temperate and 
cold climates, but there other conditions step in, and open 
\vindows and other apertures for air may be largely resorted to. 

Of course the admission of a definite quantity of air into a 
room means the removal of an equal quantity from the room. 

Consequently, 3,000 cubic feet being the quantity to be 
removed, we must now consider how often we can change 
the air of a room without producing a draught. This must 
depend upon varying conditions of temperature. 

Dr. de Chaumont's experiments led him to the conclusion 
that it would be difficult to effect a change of the air of a room 
oftener than six times in an hour under ordinary circum- 
stances. These experiments were made in barrack rooms 
affording 600 cubic feet of space. 

And the experiments of Pettenkofer led to a similar con- 
clusion. 

But even, with that amount of cubic space, this change 
would be difficult to effect without draught, unless the tem- 
perature of the incoming air was above that of the room 
occupied, because it must be borne in mind that this change 
is to go on at all times, whether windows be open or shut, 
although we cannot do away with the desirability or indeed 
the necessity of opening windows when circumstances permit. 
The problem is much simplified if, by giving a cubic space of 
1,000 cubic feet, we limit the change of air to three times an 
hour, and with an increased cubic space of over 1,000 cubic feet 
we should require even a less frequent change. It will be 
recollected that Professor Faraday showed by experiments, 
that a velocity of two feet per second would not be perceptible, 
and with properly arranged inlets, no draught need be felt 
with a change of air of three times per hour. 



v.] 



Quantity of Air Necessary, etc. 



59 



The position of air inlets both in relation to their level and 
inclination will be alluded to in connexion with movement of 
air. But it will be convenient here to add a few words on the 
measurement of the quantity of air passing through inlets or 
outlets for purposes of ventilation. The only way in which 
actual measurements can be taken is by causing the air to 
pass along a channel the size and area of which is known, and 
then to measure the velocity with which the air passes through 
this channel. The multiple of the area into the velocity in 
a given time gives the volume which passes through in that 
time. It is, however, somewhat difficult to obtain correct 
results, because so many eddies accompany the flow of air 
in a tube, which are further aggravated by the introduction of 
measuring apparatus. 

The velocity of the air may be measured in various ways. 
It may be measured by puffs of vapour of turpentine, or by 
balloons filled with hydrogen and weighted to be of the exact 
specific gravity of air^ the time occupied by the puff of vapour 
or balloon in passing along a measured length being accurately 
ascertained. 

For low velocities, it is worth noting that a sheet of light 
tracing paper, moved through the air at 2 feet per second, 
takes up an angle of 45°, and affords a ready means of 
measuring that velocity ; and, for smaller velocities, the angle 
assumed by the flame of a candle affords a fairly accurate 
index according to the following table : — 



Velocity of flow of air. 
Feet per second. 


Angle of inclination of flame 
of candle with horizon. 


1.6 
1.0 
0.75 
0.50 
.40 


60° 
64° 



6o Healthy Hospitals. [ch. 

In other cases, where the flow of the air is more rapid, an 
anemometer may be resorted to. An ordinary form of ane- 
mometer is that of vanes fixed to a spindle, the revolutions 
of which are recorded by a counter. The vanes are turned 
by the direct action of the current of air, and the number 
of revolutions which are recorded by the counter gives 
the velocity. The vanes will only begin to move after 
the current of air has attained a certain strength, depending 
upon their weight and form, and this method of measure- 
ment is therefore not applicable to very low velocities. Of 
course the value of the revolutions has to be ascertained 
in the first place by direct experiment ; that is, by forcing 
a known bulk of air through a channel of a given size, and 
ascertaining the number of revolutions made by the vanes 
at different velocities, and thus obtaining the equation for 
the particular instrument. Another method of ascertaining 
the value of the revolutions is to move the instrument itself 
through stagnant air at given velocities. On account of friction 
the number of revolutions corresponding to a given volume 
of air when the current of air is moving slowly, does not 
necessarily correspond with the number of revolutions re- 
quired to measure the same volume of air when the current 
of air is rapid. The currents prevailing in the room, where 
the measurement takes place, have also an appreciable effect 
on the movement of the vanes. 

The most convenient apparatus for the purpose of measuring 
the relation between the motion of the vanes and the rate 
of the flow of air, is a graduated vessel constructed on the 
principle of the ordinary gas-holder, from which a known 
quantity of air can be drawn in, or expelled at will, through a 
channel of a size to correspond with the size of the anemometer, 
and so that the whole of the air will pass over the vanes, 
proper precautions being taken to protect the channel from 
eddies. 

Fletcher's Anemometer is another very convenient form for 



v.] Quantity of Air Necessary, etc. 6i 

measuring the speed of air in heated flues. The instrument 
consists of two parts : the first part of two metal tubes of 
about y^jy inch internal diameter, open throughout, and of any 
length ; the second part, of a manometer, or pressure-guage. 
Of these tubes, the end of one is straight and plain, while 
that of the other is bent to a right angle. When in use these 
tubes are placed parallel to each other, and so that their ends 
are exposed to the current of air to be measured. They lie at 
right angles to the current, which thus crosses the open end 
of the one and blows into the bent end of the other. 

By this means a partial vacuum is established in the 
straight tube, whilst the pressure of the current forces the air 
into the bent tube ; a differential manometer, attached to the 
outer ends of the tubes, shows the excess of pressure in the 
bent one over that in the straight one. The manometer used 
is a simple U-tube of glass set vertically, containing ether, 
fitted with vernier scales, by which the difference of level of 
the surfaces of the ether in the two limbs can be measured 
to rwoth of an inch. This difference of level between the 
columns of ether becomes a measure of the speed of the 
current passing the ends of the anemometer tubes ^. The 
connexion between the tubes in the chimney and the glass 
U-tube may be conveniently made by means of india-rubber 
tubing. 

1 The law which governs the of liquid driven up the tube mea- 

speed is expressed generally by the sured in inches, and v is the velocity 

formula v = ^/ p x 28"55. The cor- measured in feet per second of air 

rections to be made for small varia- at a temperature of / degrees Fahr., 

tions of barometric pressure and under a pressure of h inches of 

temperature are unimportant. The mercury. 

corrections when required are em- Tables of the velocities corre- 

bodied in the following formula : — sponding with the readings are sup- 
plied with the anemometer, and 



V— sj p— — • X 28*55, ^^^° ^ table of correction for tem- 

29.92 459 + ^ perature. See ' Healthy Dwellings,' 

where/ is the height of the column p. 69. 



CHAPTER VI. 



PURIFICATION OF AIR. 



The necessity for placing hospitals in the middle of towns 
has introduced the double question : — 

(i) Of purifying the air which is passed into the wards, 
for the protection of the patients. 

(2) Of purifying the air which is removed from wards, 
placed in the centre of towns, in which a contagious or 
infectious disease such as small-pox is treated, for the pro- 
tection of the surrounding population. 

(i) Purification of air passed into the wards. 

In large towns the fog-laden air in the winter is always 
injurious to patients, and it may often be said that the larger 
the quantity of air introduced into a ward the greater will be 
the fog in the ward. 

In cases of bronchitis and of diseases of the respiratory 
organs the presence of fog is especially injurious, as is shown 
by a rise of mortality from these diseases in the periods of 
dense fog in London. Air filters of dry cloth and cotton- 
wool filters become easily clogged, and when clogged no longer 
prevent the passage of dirt. Moreover, they do not prevent 
the passage of fog. The system adopted in the Houses of 
Parliament, viz. to pass the air through a spray of water and 
then to filter it through dry cotton wool, does not prevent fog 
from penetrating into the building. 

A method of purification by washing the air has been 
adopted at the Victoria Infirmary, Glasgow, under the design 



Purification of Air. 63 

of Mr. William Key, which appears to fulfil the necessary 
conditions, when efficiently worked, of purification of air from 
smoke and fog. This plan has been in operation since the 
opening of the first portion of the Infirmary, April 1890. 
The Infirmary at that time contained 400,000 cubic feet of 
air-space, and it is stated that the apparatus was designed to 
renew this from five to nine times in an hour. The cold fresh 
air is drawn through the air-cleansing arrangement, by the 
agency of Blackman fans, which are placed between the 
chamber, in which the air is cleansed and then tempered by 
heat, and the flues through which it passes up to the wards. 



'f>',.->^^f-:,. Loose pverhanginq 
'■Vi-'^', Flannel. ■' 



CocoAnut Ma.Hinq 
Screen. 



Fig. 2. Section of Water Trough. 

The suction of the fans draws the fresh air down a capacious 
air inlet 16 feet x 4 feet, lined with white enamel bricks and 
open to the sky. The mouth of this inlet is placed at least 
10 feet above the level of the ground, to obviate the drawing 
into it the dust that prevails nearer the surface. 

This air from the outside is admitted to a chamber, which 
is divided in half by a close hanging screen. This screen is 
fixed to a beam near the ceiling by means of its upper side, 
and connected with a longitudinal trough extending along its 
whole length which is filled with water. The arrangement of 
the trough is shown in the sketch. The screen is 16 feet long 
and 12 feet high, thus affording nearly 200 feet of surface. 



64 Healthy Hospitals. [ch. 

The screen consists of several thousand cords of cocoa-nut 
fibre or other suitable material stretched from the upper beam 
to another near to the floor of the air-chamber. The cords 
are placed so close that they touch each other ; copper wires 
are laced through the vertical cords in horizontal rows, which 
being drawn tight, give the screen a flat surface, so that when 
finished, the screen has the appearance of coarse cloth stretched 
across the apartment ; the rough fibrous nature of the material 
breaks up the entering air into very minute streams, which 
pass through equally all over its surface. 

The screen may be formed double in order to give an extra 
cleansing or scrubbing surface when desired. 

There is a constant trickling overflow of water down this 
screen from the trough, assisted by the capillary attraction 
through the loose piece of flannel or canvas which hangs over 
the edge of the trough, which keeps the screen wet. The wet 
surface catches the dust and soot particles in the air as it 
filters through, and when once these have adhered to the 
wetted cords, no current of air at whatever velocity can ever 
remove them, but they are carried down to float off at the 
drain by the flushes of falling water. For this purpose an 
automatic flushing tank is fixed in a position whereby 
20 gallons of water is instantaneously discharged over the 
surface of the screen either once, twice, or three times an hour, 
as may be necessary, to flush and remove any accumulation 
of wetted dust, soot, or germs which may not be removed 
from the screen by the trickling water over its surface. This 
goes on automatically day and night. 

The wetted surfaces of the air filtering screen is a decided 
improvement over any dry cloth or cotton-wool screens, be- 
cause these must be frequently renewed as they become foul, 
and the dry process after a time will allow dust particles to 
pass through. The wet screen automatically flushed prevents 
this. 

The area of the screen should be such as to allow the air 



VI.] Purification of Air. 65 

to pass through at a rapidity of not more than from 2 to 4 
feet per second ; a lower velocity would be better, because if 
air is forced rapidly through a screen it cannot fail to carry 
dust with it ; this is very apparent in using dry cotton- wool 
filters. 

After passing the wet screen the air is warmed by coming 
in contact with steam-heated coils erected on a wooden plat- 
form. There are eight distinct coils in the air-chambers on 
this platform ; the steam to each coil is admitted by means of 
a gun-metal wheel valve ; the attendant may turn on one or 
more of the coils, or admit only a thin stream of steam to 
each, and thus increase or modify the temperature of each 
coil at pleasure. The coils are clustered in a space 16 feet 
long by 9 feet high, and formed of the best hydraulic tubes 
\ in. bore. During winter it frequently occurs that the 
mornings are bitterly cold, with keen frost, and provision is 
made for warming the air accordingly; but by eleven or twelve 
o'clock the sun shines forth and the air becomes warm and 
pleasant, to be followed in an hour or two by the air again 
becoming intensely cold. To meet this emergency, doors are 
erected between the incoming washed air and the heating 
coils ; there are six of these doors, of which one or more can 
be opened or closed at will. When all are closed, the heating 
coils are cut off, and the incoming air prevented from coming 
into contact with them ; or one or more only are closed, 
according to the temperature desired ; and while this is so, 
there is also provided a corresponding number of bye-pass 
doors, which are opened under the coil platform, so as to bye- 
pass the air which is prevented from passing through the 
heating coils by the upper doors being shut ; in this way 
the attendant can keep the temperature uniform, and make 
alterations as rapidly as they take place in the external 
air. In opening one or more bye-pass doors, and closing 
those in front of the coils, the cold air which passes through 
mixes with the warmed air from the coils as it passes through 

F 



66 Healthy Hospitals. [ch. 

the air-propeller, and is forced inwards at the desired tempera- 
ture. Thus the temperature of the air can be changed with- 
out waiting for the coils to cool down, after shutting off the 
steam, or withdrawing the furnace fire as is generally the case 
when hot-water pipes are in use to warm the incoming air ; 
this system of tempering does not reduce the volume of air 
moving inwards. 

It is practically a modification of the system of steam coils 
used for regulating the temperature in the Houses of Parlia- 
ment. 

One of the chief advantages of the washing screen has 
proved to be the facility with which it removes every vestige of 
fog. During the winter of 1890-91 and 1891-92 there were 
many days of fog of great density in Glasgow^ yet within this 
building, so soon as this screen was passed, the air is stated 
to have been beautifully clear and bright. 

{%) Purifying air which is removed from wards in the case 
of infectious disease. 

This question was raised by the Royal Commission on 
Small-pox and Fever Hospitals, which reported in 1882. 

They stated that 'We find in each epidemic period an 
excessive incidence of small-pox in the neighbourhood of the 
hospital as compared with that at a distance. 

* Comparing epidemic with epidemic, we find that the 
aggregate incidence varies with the amount of hospital 
operations. 

' Analyzing the incidence, we find that the proportion of 
houses invaded by small-pox decreases as they are more 
distant from the hospital, with a regularity strongly suggestive 
of a natural law. 

' And examining the incidence from fortnight to fortnight, 
we find that the number of cases of small-pox arising in the 
neighbourhood varies generally with the number of acute 
cases under treatment in the hospital. 

'In a special and carefully studied outbreak of disease, we 



VI.] Purification of Air. 67 

find a large number — an unusually large number, it is said — 
of independent cases which cannot, after the most minute 
inquiry, be connected with the personal communications of 
the hospital, or with any other source of infection by contact, 
and particularly that the houses on the lines of human inter- 
course have not suffered more than other parts of the same 
neighbourhood. 

' We feel that so long as it is not proved that " personal 
communication " is adequate to the explanation of the whole 
spread of small-pox, and so long as distant " atmospheric 
dissemination " is not shown to be in the highest degree 
improbable, so long it is essential that in the construction and 
management of small-pox hospitals, both sources of danger 
should be, with the utmost care, guarded against. 

' It is of paramount importance that the areas of the small- 
pox wards, as well as their administration, should be rigorously 
separated from those of the fever hospitals ; and further, that 
their construction should be such as to reduce within the 
smallest limits the chance of spreading infection. We fully 
believe that contrivances for this purpose might be devised.' 

In the Appendix to that Report, Dr. Burdon-Sanderson 
recommended a plan by which the air of small-pox wards 
should be passed through a heated disinfecting chamber. But 
to this particular plan Surgeon-General Billings pointed out 
certain practical objections. 

In 1888 a Committee of the Metropolitan Asylums Board 
drew up a plan for the effectual purification of all infected air 
from small-pox wards for a limited number of patients, to be 
applied to a ward attached to the Western Fever Hospital at 
Fulham. In consequence, however, of the freedom from 
small-pox in London resulting from the effectual isolation of 
individual cases by their removal to the hospital ships in the 
Lower Thames, the subject has remained in abeyance. As, 
however, this is the only serious plan which has been drawn 
up by a competent engineer, to effect the purification of the 

F 2 



68 Healthy Hospitals. [ch. 

infected air of a hospital ward before it is passed into the 
atmosphere, it will be useful to explain it here. The method 
by which the proposal was to be carried out was placed in the 
hands of Mr. E. A. Cowper, C.E., of Great George Street, 
S.W., to design. 

There was a vacant and incomplete ward. No. 6, which the 
Committee suggested should be connected with a furnace 
placed in the yard, to draw from the ward all air that passes 
into it; the air to be then subjected to a scorching heat in the 
furnace, by passing some of it through the fire, and the rest 
immediately over the fire into the flame and products of com- 
bustion arising from the fire. 

The Committee further suggested that the waste heat 
should be utilized in cold weather to warm the ward itself, by 
means of a boiler and hot-water pipes. 

These suggestions were carried into effect as follows : — 
In order to ensure the absolute abstraction of all vitiated air 
from the ward, all air that entered the ward was to be drawn 
from it, passed through or immediately over the fire by means 
of a tall chimney, say loo feet high, to cause a strong draught 
from the ward, through flues to the fires ; and in order to have 
these means entirely under control, the admission of external 
air into the ward was arranged to be connected with the hot- 
water pipes for warming it in winter, and was passed through 
a number of valves regulated by wooden slides. On occasions 
when there might be a high wind on one side of the building, 
the slides on that side would be somewhat closed, so that no 
excess of air could enter. The windows would all be close 
and air-tight. Thus the draught of the chimney would at all 
times tend to cause air to enter the ward, and would never 
allow any air to pass out of the ward except through the flue 
to the fire and thence up the chimney. 

It was proposed to divide the building into two wards, one for 
six men and the other for six women ; they would be entirely 
separate, with a room for a portable bath, and water-closets 



VI.] 



Purification of Air, 



69 




JO 



Healthy Hospitals. 



[CH. 




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Purification of Air. 



71 



for each ward ; the whole entered from one vestibule or 
entrance-hall, shut off from both wards by doors. 

The furnace would be divided, so that there would be two 



era' 



ft 




fires for the better convenience of bringing the air to be burnt 
through moderate-sized openings on each side of each fire, 
both above and below the fire-bars, so as to ensure every 
particle of air being thoroughly burnt or scorched ; then, by 



72 



Healthy Hospitals. 



[CH. 







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VI.] 



Purification of Air. 



n 



means of dampers both above and below the fires and an ash- 
pit closed in front, to prevent the outside air entering, the 
action of the fires and the rate of combustion could be entirely 
under control, there being only an inrush of outside air at the 
moment of adding fuel or drawing out ashes. If at any time 
one ward had patients in it and there were none in the other, 
one fire would be sufficient for that ward ; and in case of any 




Line 



\' 






ScAle .10 Feet Co I Inch. 



A. Stoke Hole. 

B. Air Chamber 

C. Furnace. 

D Pyrometers. 

£. Boiler. 

J^. Chimney Flues. 



G, Dampers. 

//. Chimney. 

/. Opening to clear Chimney. 

K. Extraction Flue. 

L. Return Pipe. 

M. Flow Pipe. 



Fig- 7- 



O. Stand Pipe 
Cross Section through Furnaces 



slight repairs to the brickwork of one of the furnaces, the 
other could be kept at work. There would be valves in the 
hot-water pipes, to shut off either ward. 

The boiler would be placed immediately behind the furnace, 



74 Healthy Hospitals. [ch. 

so that the hot air and products of combustion could pass at 
once around the outside, and then through tubes towards the 
front, and back through return tubes, and through a damper 
to the chimney flue. When the boiler was not wanted (as in 
warm weather), this damper would be shut, and the products 
of combustion would not go round the boiler, but pass straight 
to the chimney through a damper in the flue, which would be 
opened for the purpose. Thus the boiler, which would be low- 
pressure, could be used or not as desired. 

A small supply tank, with ball-cock and overflow pipe, 
would be fixed above the pipe. 

A coke store would be formed immediately outside the 
stokehole to the furnaces. 

The arrangement of the hot-water pipes would be in two 
rows of 4-inch diameter pipes around the wards near the 
floor and close to the walls. These would be boxed in, and 
the external air would be admitted in regulated quantities by 
slides, as before mentioned, and impinge immediately against 
the hot-water pipes. 

The air so warmed in the boxed-in space would then be 
admitted to the ward, in such a manner as entirely to prevent 
any draught being felt in the ward, notwithstanding the 
enormous quantity of air that would pass through, and (so to 
speak) sweep out the ward continually. It was arranged for 
the air to be passed into the ward at a velocity of not more 
than 2 feet per second, so that it should not be felt as 
a draught. In order to ensure this, there would be thousands 
of holes of three-quarters of an inch in diameter, in the front 
and top of the boxed-in space (except behind the beds), thus 
admitting the warmed air at a limited velocity into the ward. 

Hinged covers, like the lid of the box, would close the 
holes in the top of the boxed-in space at any given point 
where it was thought advisable to further limit the intro- 
duction of air. 

In order effectually to sweep out any vitiated air from the 



VI.] Purification of Air. 75 

ceiling or upper part of the ward, and to prevent cold down- 
draughts in the ward itself, another line of 4-inch hot-water 
pipes would run round the ward just above the windows, and 
be boxed-in and be provided with slides also. 

The air would be extracted from the place where vitiated 
air would be most likely to exist, viz. from the water-closets, 
and the air from the ward would pass through the water- 
closets and away to the fires, as before mentioned. 

An arrangement of levers would be applied to the external 
doors, to balance the pressure of the external air against 
them, due to the partial vacuum caused by the draught of the 
chimney. 

There would be a vestibule or entrance-hall, with double 
doors to admit of a ' stretcher ' being brought in, and there 
would be a small lavatory for each ward, and place for 
a portable bath besides the water-closets, all separated from 
the wards, from which the air would similarly be drawn away 
to the furnace. 

The temperature to which the air would be subjected 
depends materially upon the rate at which the coke fires are 
urged, but there should be no difficulty in raising the tempera- 
ture to 600° Fahrenheit or higher, so as thoroughly to burn or 
scorch it. 

If preferred, an arrangement might be added by which 
super-heated steam would be thrown into the air as it reached 
the fire. 

A ready means would be arranged of ascertaining if the 
air had been brought to the proper temperature by the 
furnaces, so as thoroughly to burn or scorch it ; this would 
be by means of several rough pyrometers, consisting of iron 
tubes closed at the bottom and partly filled with lead, and 
fusible alloys having different fusing temperatures ; then there 
being an iron wire loose in each tube, the fact of the alloy 
being melted or otherwise could be ascertained in an instant, 
by just pulling the wire up and down a little. 



']^ Healthy Hospitals. 

A laundry would be placed outside the ward, but within 
the enclosing wall, which would separate the small-pox ward 
from the whole of the remainder of the western hospital ; 
there would be a 9-inch flue from the laundry to the furnaces. 
There would be also a small mortuary outside the ward, and 
entirely detached from it ; this would also have a 9-inch flue 
to the furnaces. 

A light corrugated iron roof would cover the furnaces, the 
boiler, and the stoke-hole. 

The furnaces, chimney and flues are arranged for entirely 
emptying the wards of air four times an hour, which might 
be pushed to six times an hour. The boiler and hot-water 
pipes are arranged to warm the air, when changed four times 
an hour, in cold weather. 

The cost of the disinfecting and warming apparatus was 
estimated at £']<)o, exclusive of any alterations to the walls 
or roof of the building, partitions, &c. 



CHAPTER VII. 



MOVEMENT OF AIR. 



The next point for consideration is the movement of air. 

Air of the composition mentioned, viz. 310 oxygen to 790 
nitrogen, is a heavy body. At a temperature of 33°, and with 
the barometer at 29-9, the mean sea-level, dry air weighs ^^6 
grains per cubic foot. The pressure of the atmosphere on 
,any surface is about 14-6 lbs. to the square inch. 

The molecules of air are but feebly attracted to each other, 
and small increases of temperature, or slight diminutions of 
pressure, separate the particles from one another, and thus 
one cubic foot of expanded air weighs less. Similarly, small 
decreases of temperature bring the particles nearer together, 
and make the cubic foot of cold air heavier than the standard 
above mentioned. This expansion and contraction is equal, 
for equal increments or decrements of temperature. And the 
following table shows the density of air at different tempera- 
tures : — 

Weight of Air per cubic foot binder 30 inches 
pressure of Merctiry. 



Temperature. 


Dry Air. 


Air saturated 


Fahrenheit. 


with vapour. 




Grains. 


Grains. 


0° 


606.37 


606-03 


20° 


581.05 


580.26 


32° 


566.85 


565.58 


40° 


55777 


556-03 


50° 


546.82 


544-36 


60° 


536.28 


532.84 


80° 


516.39 


509.97 


100° 


497-93 


486.65 



78 Healthy Hospitals. [ch. 

At 60° temperature, therefore, it may be assumed that 
13,100 cubic feet of air will weigh about 1,000 lbs., and that 
I lb. of air will measure about 13-1 cubic feet, and i ton of 
2,000 lbs. will measure 36,200 cubic feet, whilst i ton of 
3,000 lbs. of air at 100° would measure about 28,600 cubic feet. 

It follows that as warmed air expands it ascends, and as 
cooled air contracts it falls. It also follows that as the 
warmed air ascends, the air around rushes in to fill its place. 
Everywhere this heating and cooling of the air is going on ; 
the sun's rays, the proximity of a warm body, the vicinity of 
a cool shaded surface, all cause movements in the currents 
of air. 

In the ventilation of hospitals we have to consider the 
movements of air under the heads of — 

I. Movement of Air caused by difference of temperature. 
{a) By the movement of the atmosphere. 

{b) By the movement of Air, caused by the artificial 
application of Heat. 

II. Movement caused by the application of mechanical 
appliances, viz. fans, blowers, or other such methods of pro- 
pelling or extracting air. 

There are, however, certain preliminary considerations 
which it may be well to attend to here. 

The change of air in a closed space effected by suction 
draws in through every available opening the air required to 
replace that drawn out, it is therefore essential that those 
openings which afford only pure air should be more easily 
accessible than those through which impure air may arrive. 

Propulsion, on the other hand, would provide only pure air, 
and as this comes in under some degree of pressure it would 
prevent the air from impure sources from passing into the 
closed space. In one case the air which replaces that drawn out, 
in the other case the air forced in, will require warmth in this 
climate in winter. This subject will be treated further on. 

The velocities at which air should either enter a room or 



VII.] Movement of Air. 79 

should pass out of the room should be equally regulated ^ ; 
in neither case should the current, as it passes from the room 
or into the room, ever exceed 1 feet per second, hence the area 
of inlet and outlet should be so regulated. 

The slow, equable and continuous movement will more 
effectually affect the air in the room. If incoming air is 
admitted through or near the ceiling, its velocity should not 
exceed i foot to i foot 6 inches per second. 

After the air has left the room the channels may be 
arranged to produce an accelerated flow, gradually increasing 
at its departure from the propelling engine, or on its arrival 
at the extraction chimney to 6 feet and 7 feet per second. 

This may be a convenient place to say a few words on 
flues, for bringing or removing air. 

The position of the openings for the admission and removal 
of the air is a point of importance ; none of these should be 
made through gratings in floor, as is too often the case, 
because they are exposed to fouling and obstruction by 
sweepings and rubbish from the floor. 

The openings for the admission of fresh air, whether warm 
or cold, should be placed at such a height that no person may 
receive the impression of a draught. The most favourable 
position appears to be from six to nine or ten feet from the 
floor according to the height of the room, the air being 
directed upwards. The openings for the abstraction of the 
air should on the contrary be placed generally in the side 
wall, 3 or 4 inches above the floor level, with an upward slope 
at the back to prevent lodgement of dirt. 

There is also the necessity of absolute cleanliness being 
maintained in air flues ; they are naturally receptacles of dust, 
which is deposited either from the outer air or from the air of 

^ Movement of air of 55°-65* F. most; at 3J feet, felt by all; at 

At \\ feet per second (i mile per 4 feet, felt as a distinct draught, 

hour) felt by none ; at 2-2J feet per Vide Willoughby's ' Health Ofificer's 

second, felt only by a few very Pocket-Book,' 1893. 
sensitive persons ; at 3 feet, felt by 



8o Healthy Hospitals. [ch. 

the room. The dust in an inlet flue prevents any pure air from 
entering the ward. This is an evil, contingent on all con- 
cealed dark passages. Freedom from dirt can only be secured 
in air flues by exposure to ample daylight. Indeed the actinic 
rays of light have been proved to be germicidal in the case of 
certain micro-organisms and spores. 

Moreover, dust and dirt check the velocity of air in air- 
passages. 

General Morin found that the presence of a cobweb in 
a flue almost entirely checked the passage of air. 

The main conditions to be attended to in the design of air 
channels, apart from smoke flues, are that they should be 
as straight as possible so as to be seen through ; they should 
have smooth sides ; and they should be capable of being easily 
cleaned. Gratings are necessary at the openings at either 
end ; but they facilitate the lodgment of dirt and should be 
easily removeable for frequent cleansing. 

I. Movement of Air caused by difference of temperature. 
(^) Movement of Air due to the Atmosphere. 

It may be premised in the first place that, when the wind 
blows, there is a tendency for air to be forced into a building 
through openings on the side against which the wind is 
blowing, whilst there is an exhaust caused on the opposite 
side, which tends to draw air out of the building. Thus if 
a room has open windows, or other openings on opposite 
sides, the movement of the atmosphere across the building 
causes one opening to become an inlet and the other an 
outlet. Similarly, any opening, leading from the outer air 
into a closed space, which is either turned away from the 
wind, or across which the wind blows, becomes a means of 
extraction, dependent however to a certain extent upon the 
inlets through which the outflowing air can be replaced. 

For instance, the windsail of a ship turned from the wind 
acts as an extraction shaft, whilst the windsail turned towards, 
the wind propels air into the hold. And in the case of a 



vii.] Movement of Air. 8i 

chimney flue there is always a current dependent upon the 
movement of air across the top of the shaft of the chimney, 
whether it contains a fire or not, and a similar movement 
is caused in every flue which terminates in an opening across 
which the wind blows, or in an opening turned away from the 
wind. This acts always to create an extracting current. 

This upward current will always prevail in a chimney or 
main air-shaft, except where there are strong counteracting 
influences, such as conditions interfering with the smoothness 
or cleanliness of the flue, which will be alluded to further 
on ; or we may instance — 

(i) In a very cold chimney on an especially warm day, 
with a small movement in the outside air. 

(2) If the room in which the fireplace is situated is 
connected with a large central staircase, which itself acts as 
a more powerful shaft. 

(3) If the room is connected with other rooms which have 
fireplaces in which are lighted fires, or with other parts of the 
building, which may themselves act as shafts to draw air down. 

(4) If the chimney flue be very large, and if there are 
not adequate inlets to supply it with fresh air, a double 
current may be established within the chimney, one up and 
one down, and thus impede the draught. 

(5) The upward current may also be occasionally checked 
by the fact that want of elevation of the top of the chimney 
with respect to adjacent buildings prevents the free move- 
ment of the atmosphere across it ; or if the chimney flue 
terminate in an opening placed to meet the wind, air will be 
forced down it. 

The movement of air in a vertical shaft, caused by this 
action, is of course unequal in its effect. It is powerful when 
the wind is high. In calm weather it is very small ; but in 
this country, as already mentioned, the average velocity of 
the atmosphere is above 17 feet per second, and it is rarely 
quite at rest. 

G 



82 Healthy Hospitals. [ch. 

It is very difficult to measure the relation which the current 
in a tube or shaft caused by this method of extraction 
bears to the velocity of the wind, because there are so many 
conflicting elements to be considered. The formulae for 
calculating the velocity of wind in some of the standard 
anemometers are not entirely satisfactory — especially for very 
low velocities. 

The wind, whilst it acts as an exhaust for the air which 
passes up through the tube, is, at the same time, acting on all 
other openings in the building, either to exhaust or to force 
in air. Hence gusts of wind will sometimes cause a reverse 
action in the tube, in consequence of some other opening 
acting temporarily as a more powerful means of extraction. 

The friction in the shaft varies inversely with the area ; 
and with small tubes it forms a very perceptible element of 
retardation. 

With experiments made with tubes 3 inches in diameter 
the velocity obtained in the tube was about f of that of the 
wind ; larger diameters, on the other hand, produced from 
I to I the velocity of the wind. These results were obtained 
in a place supplied, as conveniently as possible, with fresh 
air to replace that removed, in a manner independent of the 
movement of the atmosphere ; moreover the top of the tube 
was freely exposed on all sides. 

The temperature inside and outside must also be con- 
sidered. 

If the atmosphere be without perceptible movement in 
cold weather, when the temperature indoors is maintained 
for comfort above that out-of-doors, the difference of tem- 
perature will cause an upward movement in the shaft. In 
hot weather, if the shaft is colder than the outer air, a down 
current may ensue ; but if, in hot weather, there should be 
little or no movement in the shaft, this occurs at a time when 
the windows can be kept open, and the air be renewed by this 
means. The top of any shaft should be raised well above 



vji.] Movement of Air. 83 

the ridge of the roof, to ensure clear exposure to the air, and 
it is desirable that the edges should be sloped upwards. 

In consequence of the numerous causes of disturbance 
enumerated above, this method could not be relied on to 
act on all occasions with certainty as an extraction-shaft. 
But it can be relied on to ensure in one way or other, and to 
a certain extent, a continual change of air. 

A tube or shaft with an open top acts best. It is, however, 
necessary to protect the top by some form of cowl, to pre- 
vent rain from entering the tube. The efficiency of the shaft 
or tube depends upon the area of the outlet upon which the 
winds acts, which blows across its top. Whatever be the 
shape of the cowl, if it afford only the same area of outlet as 
the shaft, it will delay the current more or less, dependent 
upon its shape. If the cowl is made to afford a larger area 
of outlet than the shaft or tube, the current in the shaft or 
tube may be increased according to the form of the cowl. 
What are termed air-pump cowls or exhaust cowls will be 
effective in proportion as they are larger than the tube or 
shaft. A cowl with a curved head, arranged to move round 
with the wind, so as always to present its back to the wind, 
would appear to be the form of covered top best adapted to 
facilitate extraction, especially if gradually enlarged at its 
mouth into an oval shape, with an aperture larger than the 
tube. But the objection to a moveable cowl is, that if by any 
accident it failed to turn, it would become a powerful inlet like 
the windsail on a ship. To obviate this Boyle's or Buchan's 
cowls are arranged with fixed blades, which divert the direct 
action of the wind, and this causes them always to assist the 
exhaust ; and they moreover afford an area of exhaust on 
every side considerably larger than the area of the tube. 

It may be well here to point out that where, as in a one- 
story ward, or a ward on the Toilet plan, the ridge is used 
as an outlet, the ward itself becomes the upcast shaft, and 
draws in the air from inlets below. If all inlets below the 

G % 



84 Healthy Hospitals. [ch. 

ridge level were, or could be closed, then the ridge ventilator 
would act like a Watson ventilator, and furnish an upward 
and a downward current. 

{b) Movement of air caused by the artificial application of 
Heat. 

The law which regulates the movement of the air in a con- 
fined space, when its temperature is higher than that of the 
outside air, depends upon the following considerations : — 

(a) Upon the difference of temperature of the air inside 
the confined space, as compared with that outside. 

(b) Upon the area of the aperture through which the air 
passes. 

(c) Upon the height of the column of ascending air of 
the higher temperature. 

If F = vel. in ft. per sec. ; 
H = height of shaft ; 
/ = temperature in shaft ; 
ti = temperature out of doors ; 
a =■ the co-efficient of dilation of air which for 
1° Fahr. = -00203 ; 

the theoretical equation for calculating velocity of air in a 
shaft becomes 



F= 8-034 V^^«(^-^i). 

But the actual movement of air is very different. 

It is diminished by the resistance which increases directly 
with the length, and inversely with the diameter or area of 
the flue ; and it also increases with the square of the velocity 
of the air currents. The resistance is, moreover, much influ- 
enced by the material forming the sides of the flue ; with 
a sooty flue the velocity, with equal temperatures, has been 
found to be one- half that of a clean flue. 

General Morin states that the following relations between 
the volume and temperature of the air and the areas of the 



VII.] Movement of Air. 85 

air flues have been obtained from theory and practice com- 
bined : — 

V=C V{T-T)H. 

Q^CA J{T-T')H. 
In which — 

A — sectional area of the exhausting flue ; 

H = height of exhausting flue ; 

T = average temperature of air in flue ; 

T^ = temperature of external air ; 

C — co-efficient, constant for each air-flue as regards 

its proportions and arrangement ; 
V = average velocity of air in flue ; 
Q = volume of air passed per second. 

The results derived from these relations are, that the velocity 
of the escaping current is proportional to the square root of 
the excess of the temperature of the heated air in the flue 
over the external air, and also to the square root of 
the height of the flue or chimney; and the volume of air 
extracted is consequently proportional in addition to the 
sectional area of the flue. 

The calculations depend upon the co-efflcient of resistance ^. 

^ Peclet, in his treatise on the to be .0127 ; sheet-iron chimneys 

application of heat, has given the to be .005 ; and cast-iron chimneys 

following formula to include some to be .0025. 

of the resistances : This formula gives rather too 

2s:aH{t-t^D ^^S^ results. Phipson suggested 

^^ = D^^gHK ' "^^^^ v^ = DH{t-t,) ^ 

L + 16D 

D = diameter of shaft, circular , r 1 xu r 

a ^ r r where L = length of evacuation 

flue, or sq. root of area 01 , , tt ^ • 

' , . channels. Hurst gives 

rectangular flue; i^DH{t-t\ 

H = height of shaft ; V"" = ^ ^ ^^' , 

K = the co-efiicient of resistance ; ^ "^ ^^ 

t = temperature of shaft ; where the dimensions are in feet, and 

^1 = outside temperature. K = -02 for clean glazed earthen- 

And he determined the co-efficient ware flues, .03 wood flues, -06 sooty 

of resistance, corresponding to this flues, 
formula, due to pottery chimneys 



S6 Healthy Hospitals. [ch. 

The difficulty of obtaining a uniform co-efficient for the 
resistances will be made apparent from the fact that in flues 
of the size of ordinary chimneys, soot or accumulations of 
dust on the sides seriously affect the velocity. 

And in this respect the material of which the flue is com- 
posed is of importance. The ordinary open fire is a simple 
form of extraction, and with it a cold flue produces much 
more soot than a flue which has warm sides would do, 
apparently because the molecules which are heated rush with 
more force to adjacent cold surfaces than would be the case 
with a warm surface. It is apparently also for this reason 
that hot-water pipes in a room cause dust to accumulate on 
adjacent cold objects. 

The above formula shows that the two elements of the 
calculation which govern the flow of air in a heated extracting 
shaft are difference of temperature and height. Consequently 
a high shaft with a moderate temperature may be as efficient 
as a lower shaft with a big fire. Hence an expenditure of 
capital in construction may economize in cost of working. 

In an extraction system the size of the upcast flue from 
a room, as compared with the inlets for air to replace that 
removed, may also to some extent affect the flow of air in 
flues. 

If the upcast flue is large, and if the inlets are not large 
enough to supply an adequate amount of fresh air, a double 
current, one up and one down, on the principle of the Watson 
ventilator, may be established in the upcast flues. This is 
a reason why chimney flues sometimes smoke when too large, 
and why the draught of a chimney flue is improved by contraction 
at the top, to prevent the formation of a double current. 

An aspirating or ventilating chimney is a shaft or flue so 
constructed that the air in it can be heated without neces- 
sarily heating the room or rooms from which it is desired to 
withdraw the air, so that no discomfort need be caused by its 
use in warm weather. 



vrr.j Moveme7it of Air. 87 

In buildings where the architect desires to provide a cen- 
tralized form of heating and ventilation, he will probably 
desire to unite his exhaust flues into a few or possibly one 
upcast shaft, because with one large chimney the friction is 
reduced to a minimum, the arrangements for control of the 
velocity can be simplified, and all risk of one aspirating shaft 
p"ulling against another is avoided. But the question as to 
the employment of one or more shafts must be determined by 
the plan of the building and the possibility of placing the 
shaft in a nearly central position. 

When one shaft is used for a large number of rooms or 
halls, it may be convenient to utilize heat of the smoke-pipe 
from the heating apparatus to warm the ventilating shaft, but 
the limit to which this method of warming could be carried 
would be determined by the point at which it checked the 
draught from the furnace. 

In the case of a hospital with superimposed stories, the 
collection of the ventilating flues from the wards into a central 
shaft may be effected in three different ways, premising however 
that the heating power ought for efficiency to be applied at a 
point above the entrance of all foul-air flues. 

(j) All the foul-air flues from the wards may converge 
into a single shaft, commencing above all the rooms, in con- 
nexion with which is a furnace or coil of steam-pipe in the 
roof to give additional heat and ascensional force to the air. 
In this case the number of flues in the walls increases with 
the height, and the shaft begins only in the attic, and 
may be made of wood, if properly lined, or of galvanized 
iron. 

(2) The foul-air flues of each story may be carried hori- 
zontally to the central shaft, which they enter at the level of 
the ceiling. 

(3) All the foul-air flues may be carried downward below 
the level of the lowest ward-floor and into the central extrac- 
tion-shaft at the bottom. 



88 Healthy Hospitals. [ch. 

In this latter case the number of flues increase in the lower 
stories, and the lower walls must be made thicker. 

The size of the upcast shaft, however, would be somewhat 
smaller than that in the first case, because the aspirating power 
of the shaft depends on the height of the heated column of air, 
as well as on the difference between the temperature in the 
shaft and that of the external air ; hence the nearer to the 
bottom of the shaft the heat is applied, the greater will be its 
efficacy. The shaft in the third case would, however, be of 
brick, hence its size becomes an important consideration : for 
if the velocity of the air in it should not exceed six feet 
per second, the volume of air at 3,000 cubic feet per hour for 
about 260 persons, would be, say, 316 cubic feet per second, 
and the chimney must have 0,6 square feet of clear inside area, 
and as such a shaft will probably reach 100 feet in height, 
requiring thick walls at the bottom, it will be found necessary 
to provide nearly 100 square feet for it. 

On the other hand, the application of heat to the central 
shafts can be arranged more easily and to much better advan- 
tage in this latter, the third, system, than in either of the 
others. 

During the winter the heat needed for producing an upward 
current in the shaft can be obtained in most cases from the 
smoke-flue of the heating apparatus, while in summer a small 
furnace can easily be connected with the side of the base of 
the shaft. 

With the tall shaft it will generally be found most con- 
venient to apply the accelerating heat by means of a coil of 
pipes, suitably arranged for radiation in the shaft and heated 
by steam or hot water, or by means of an open grate placed 
in the shaft, as is done in the aspirating tower for the House 
of Commons, and in mines, or by means of a stove, heating 
a sheet-metal pipe passing up the chimney, or by gas jets. 

The open grate is a troublesome and not an economical 
mode of applying heat for this purpose. The use of gas jets 



VII.] Movement of Air, 89 

is expensive if the amount of air to be moved be large, but 
it should not be forgotten that the burning of gas for illu- 
minating purposes gives rise to heat which can often be used 
advantageously for purposes of ventilation. 

Good results are afforded by the plan above mentioned of 
heating the aspirating chimney by means of a central metal 
pipe, carrying the waste heat from the flues of steam boilers, 
&c. It has been computed that for a building four stories high, 
if the amount of coal necessary to heat the shaft be assumed 
in the first system, when the shaft commences in the attic, as 
i-o, it would require -78 in the second, and -58 in the third, 
with the ventilating flues collected at the bottom of a tall 
shaft. 

Box ' on Heat,' Billings' ' Heating and Ventilation,' and 
Baldwin's 'Steam Heating,' afford data for calculations. And 
the following formulae are here quoted as published by Mr. 
Trowbridge, of Columbia College, in the 'Sanitary Engineer' 
of New York, for calculating the heating surface by coils of 
steam pipes, required in ventilating flues for producing a given 
discharge of air. 

' The formula is as follows : 

WT 

' In this formula 5 represents the number of square feet in 
the exterior surface of the coil or cluster of steam pipes at the 
base of the flue ; 7"„ is the absolute temperature of the ex- 
ternal air — that is, the common or thermometric temperature 
-f- 459-4° (or /° + 459'4°), in degrees Fahrenheit. 

'W represents the weight of air in pounds, which is dis- 
charged in one second. 

'//" represents the height of the flue, and T^ is the absolute 
temperature of the steam in the coil, i. e. tg + 459-4°. 

' The constant 1500 is derived from certain constants which 
were employed in deducing the formula, one of which was 



90 Healthy Hospitals. [ch. 

the force of gravity, another the specific heat of air, another 
the rate of transfer of heat to air by coils, from Mr. C. B. 
Richards' experiments, and another the ratio between the 
theoretical velocity and the actual velocity in the flue, as 
influenced by friction. For ordinary and the most favourable 
circumstances, the actual velocity in the flue is best if it be 
established at about five feet per second, and it is for this 
actual velocity that the formula in its simplified form as above 
is adopted. 

' Another formula, well known, and which is needed, is that 
for the weight of air discharged per second- — to wit : 
W = Ay. D,^ V. 

' That is, the weight discharged is found by multiplying the 
cross section of the flue A by the velocity V and the density 
D^ of the air in the flue.' 

Mr. Trowbridge states that the density of the air in the 
flue which will result from the proportions given by this 
formula will be 0-0719 pounds per cubic feet. 

Hence the area of the flue for a given discharge W, 

will be: 

_ W _ W _ W 

" D,V~ 0-0719 X 5 ~ -3595 ' 

or A = ^ W approximately. 

That is, the cross section of the flue in square feet should 
be three times the weight of air in lbs. discharged per second ^. 

^ An example will show the method the weight of air discharged per 
of using these formulae for all or- hour will be 

dinary cases. 4 x 18000 x .08 = 5760 pounds, 

Suppose the air of a room 30' X 40' . , 

and 15 ft. from floor to ceiling is ^^J^'^ Pounds per sec. 

to be renewed four times every The required area or cross section 

hour. ^^" be 

The cubic contents are ^ = 3 x 1.6 == 4.8 sq. ft. 

30' X 40' X 15'= 18000 cub. ft. If now we suppose the steam in 

At the ordinary temperature and the coil to be low-pressure steam 

pressure, this air will weigh about for instance five pounds above the 

1^ of a pound per cub. ft., and atmosphere, we shall have for its 



VII.] Movement of Air. 91 

It is of great importance in arranging steam and hot-water 
pipes for heating air in its passage to flues, or to where it is 
desired to utilize the heat, that the pipes should be covered 
with non-conducting material to prevent loss of heat, and 
that the pipes should not block up the flues, but should be 
placed in an enlargement or chamber, so that the aggregate 
area through and among the pipes shall not be less than the 
area of the flue, and preferably 20 per cent, greater, so as to 
ensure a moderate velocity to the air in its passage over the 
heated pipes. 

Moreover, the pipes or heaters should be so arranged that 
no air will pass without coming in contact with the heated 
surfaces. A baffled passage, causing the filaments of air to 
assume a tortuous course among the pipes, is the proper one. 
This was the principle of the system adopted by Dr. Sylvester 
in warming hot air for the ventilation of asylums and hospitals 
more than sixty years ago, in which he used clusters of parallel 

temperature Fahr. 228°, and if we area of ventilating flue of 4^% sq. ft. 
assume the exterior temperature of in cross section, and 147 sq. ft. 
the air to be 60°, we shall have con- of heating surface in the coil or 
ditions which will apply to spring cluster of pipes at the base. 
or autumn weather, and the same If more than one flue is em- 
arrangements then determined will ployed, which would probably be 
give better results in winter or desirable, in order to have a better 
cooler weather; with these as- distribution of the inflowing air (two 
sumptions we have : flues for instance), then each would 
1 500x1.6 (60° -(-459.4) have an area of 2f sq. ft., and 

-^ -/f{(228°+4594) - (60" + 45941} f ^^ .'^°'^l^ ^.^ "^^^^f ^\ ^^^ ''^'^ 
Qj. ^ t^5"t/ V -^jy-Ti^ ^y p^p^^ havmg 73* sq. ft. of sur- 

1 500 X 1 .6 (60° -f 4594) '^'^^^' 

^ /7(228°-6o° ) ^^ "^^y ^^ thought that this 

. Q amount of heating surface as given 

= -777X500. by the formula is excessive for the 

degree of ventilation assumed. 

If the flue is 50 ft. high, we shall The reply to this objection is, that 

li'ive : if any one expects to obtain full and 

^ _ 1500x4.9 _ ,Q ^ . Q sufficient ventilation without ex- 

50 pending an appropriate amount of 

= 147 sq. ft. money, both for fixtures and for 

Hence, the conditions of ventilation fuel, such a one is mistaken.— Trow- 

assumed will require an aggregate bridge. 



92 Healthy Hospitals. [ch. 

horizontal pipes in rows one above the other, and placed a 
baffle of thin angle-iron resting on each parallel pair of hori- 
zontal pipes, so that the incoming air was compelled to pass 
through the narrow space between angle-iron and pipe. 

II. Movement of Air by Propulsion or direct force — such 
as Fans, Blowers, or some form of Air Pump. 

The direct propulsion of air may be used either to extract 
air from or to propel air into a building. 

As applied to hospital ventilation, the great utility of the 
fan lies in the power which it gives, in the absence of open 
windows, of rapidly flushing out the wards morning and even- 
ing with large quantities of air. 

The various apparatus which have been used for forcing 
air into hospital buildings may be classed under the heads of: 

1. Air Pumps; 

2. Rotary Fans, Screw Fans. 

In the application of these appliances, it should be 
mentioned that a noticeable and important defect in some 
systems of mechanical ventilation, is the pulsatory move- 
ment induced in the air current, and the noise consequent 
on the least neglect on the part of the machine attendant. 

The force necessary to propel air through any passage 
is equal to the square of the velocity into the total surface 
multiplied by the co-efficient of friction, the pressure of 
the air being uniform. 

Mr. D. P. Morrison has given as a practical formula to 
be used in ventilation, the following expression : 

KVPL 



H = 



A 



This formula is perfectly general and may be used for any 
fluid. 

H = the head of pressure, in feet of air of the same density 

as the flowing air ; 
L = the length of the pipe or passage in feet ; 



vn.] Movement of Air. 93 

P = the perimeter of the cross section in feet ; 

A = the area of the pipe or passage in square feet ; 

V = the velocity in thousands of feet per minute ; 

K = the co-efficient of friction ; for which in the case of air 

Mr. Hawksley gives 0'03. 
Taking D as the diameter for circular passages whose 
diameter is small in proportion to their length, 

and for irregular-shaped channels, 

PL + 200 A 
H = KV^x -^ • 

When this formula is applied for the calculation of the 
head of pressure H, in an apparatus for heating and 
ventilating, where the velocities and the area of channels 
have various proportions, it is found necessary to take a 
mean area, a mean perimeter, and a mean velocity for the 
whole length of the channels, without which too high a head 
of pressure would be given. 

The pressure of i foot of air at 60° Fahr. under 30 inches 
pressure of mercury is 0-0765 lb. per square foot. The 
pressure of i inch of water is 5*2 lbs. per square foot. To 
reduce the pressure in feet of air to its equivalent in inches of 

water divide it by — ^—^ =68. A pressure of yV i^^^h of 

water as a measure of the pressure of the air need rarely be 
exceeded in hospital ventilation. 

I. Air Pumps. 

The advantage of this method of air propulsion for 
hospitals is that it can be arranged to furnish a carefully 
regulated amount of air ; and, provided the size of the pump 
is large, the motion slow, and the pressure limited to what 
is necessary to send the air through the flues, it might be 
a convenient method. But as yet it has been chiefly adopted 
experimentally. 



94 



Healthy Hospitals. 



[CH. 



Dr. Arnott devised an air pump which would either force 
air into or extract air out of a hospital ward in strictly- 
defined quantities. Dr. Arnott's plan was on the principle 
of a gas holder carefully balanced, from which the air was 
forced through the air channels into, or extracted from, the 




^^^^^^J?^^?5^?5??!^!^^^^?5^^^ 



V 
a = height ot outlet = 7— • 

ai = distance from vertical radius to point e. 

h = width of vanes = — with two inlets. 

r\ 
c = velocity of air entering Fan (10 to 40 feet per second). 
cx = velocity of air leaving_ Fan. 
h — height of manometer in duct. 

n = numher of revolutions per minute = /^ h. 

r = outer radius of vanes. 

^1 = inner radius of vanes ri to 2 r^- 

r% = radius of inlets = v / with two inlets). 



/ = radius for curve of vanes : 



y2_^j2 



, in which the tangent 2"= 0-1047 



2 r\ sin s" 

describes a curve from the point e to the inner periphery of vanes. 
V = volume of air delivered in cubic feet per second. 

Number of vanes = lor., generally 4 to 6. 

Fig. S. Rotary Fan for Vacuum or Plenum Movement, according to Rittinger 
(from Schumann), 

ward. This was applied more than forty years ago in the 
York Infirmary. A pump on a somewhat similar principle 
was subsequently placed in the House of Commons by 
Dr. Percy for propelling cooled air into the chambers during 
exceptionally hot weather. 



VII.] Movement of Air. 95 

Dr. Percy adopted a double acting machine consisting of 
a light vertical piston, carried on rollers which ran on rails. 
The piston was supported on double piston rods and moved 
in rectangular chambers 6 feet 6 inches by 8 feet, with a 
travel of some 10 or 11 feet. 

The valves were of thin sheet india-rubber on wire 
seatings. The machine was driven by noiseless friction- 
gearing from a small vertical engine of four horse-power, 
and was capable, at sixteen strokes per minute, of renewing 
the air in the House in nine minutes. 

2. Rotary Fans and Screw Fans. 

A rotary fan, as shown in Fig. 8, consists of a certain number 
of tubular passages, which are rotated about a lineal axis at 
right angles to the direction of the passages, whereby a given 
volume of air is drawn into the blades at the centre and 
impelled by centrifugal force through the tubular passages 
at a determined pressure. 

A screw fan of the type shown in Fig. 9 also draws in 
the air at the centre and distributes it at the circumference 
by centrifugal force. 

In the United States the Sturtevant fan somewhat on 
this pattern has obtained a large development. 

The best action is obtained when the whole circumference 
of this fan opens into a free chamber. The effect depends 
upon centrifugal motion, and centrifugal motion is independent 
of the figure of the fan. 

Hence whatever the form of the blades, whether radial 
or curved, nearly the same pressure is produced at similar 
velocities, at least so long as the volume of flow is not very 
great. 

But in regard to the efficiency of the fan, or the ratio 
of the work expended in driving it, to the useful work in 
the air pumped, the form of the vanes has an influence. 

There are two great sources of loss in a fan or centrifugal 
pump with straight radial vanes. In a centrifugal pump or 



96 



Healthy Hospitals. 



[CH. 



turbine the condition of maximum efficiency is that the water 
should enter and pass through the wheel without any sudden 




A = sectional area of air current as it leaves the Fan = db-wivcv z\ 

A\ = sectional area of air current as it enters the Fan = di bi n sin z^". 

V = volume of air in cubic feet per second delivered theoretically = n Aci. 

k. 
V\ = volume of air in cubic feet per second delivered actually = F — 

lOO 

di 

b = vifidth of Fan outside = by—i 

a 

d 

b = width of Fan inside = b-y . 

1 di 

C = velocity of air entering Fan = • 



Ai 
rybi 



c, = velocity of air leaving Fan = . 
^ ro 

bi 

b ' 



sin sfl 



d = outer diameter of Fan = di 



di — inner diameter of Fan = d,— . 

h = height of manometer from \ inch to 2 J inches. 
k = per cent, of effect from 20 to 30. 
/ = radius for vanes = kdXo\d. 
n = No. of revolutions per second from i to 2. 
r — outer radius of vanes. 
r\ = inner radius of vanes. 
V = velocity of periphery of vanes = dnir. 

z" and 21" = angles between tangents and initial lines of vanes. 
Number of vanes = 1-5 n, generally from 6 to 16. 

Fig. 9. Screw Fan for Vacuum or Plenum Movement, according to Combes 
(from Schumann). 

change of velocity, because any sudden change of velocity 
or shock causes a waste of mechanical energy, by its con- 
version into heat. A similar effect occurs in the fan ; with 



vn.] Movement of Air. 97 

straight radial blades there is a suddea change of velocity 
at the moment the fluid enters the inner circle of the revolving 
blades, and another when it passes their outer tips. 

Hence, in order to pass the air into the revolving wheel 
without wasting energy, the inner ends of the blades ought 
properly to be inclined to the radius at an angle whose 
tangent is in the direction of the motion of the air relatively 
to the blades ; and in order to reduce the shock caused by 
the air, which leaves the blades at a high velocity and enters 
a mass of air flowing out at a comparatively low velocity, 
the tips of the blades have been recurved so as to give the 
air a backward flow relatively to the blades. 

Screw fans are not more complicated to construct than 
the ordinary rotary fans, and they are less likely to get out of 
order. They appear also, when moving at a low pressure, 
to afford the same effective power^ provided the minimum 
of resistance is given to the inlet and outlet of the air, and 
the delivery passages are of large dimensions. 

The pressure attainable by any form of revolving fan is 
low, when considered in pounds per square inch. A pressure 
equivalent to a column of 7 inches or 8 inches of water is 
attainable only at very high speeds. A pressure or suction 
of 3 inches or 4 inches is nearly as large as can economically 
be attained in delivering a quantity of air at high velocities, 
when the friction of machinery, the want of adhesion of 
belts, and certain other considerations of friction of air on 
the vanes are taken into account. 

Thus the largest differences of pressure are less than the 
ordinary atmospheric disturbances as indicated by the baro- 
meter. But, as already observed, much lower pressures may 
be made to sufifice for ward ventilation. 

Rittinger and Combes's formulae for these rotary and 
screw fans respectively, are referred to as applicable in 
calculating for the sizes of fans, and for the horse-power in 
proportion to the volume of air required ; and according to 

H 



98 



Healthy Hospitals. 



[CH, 



these formulae, it would seem to require from 50 to 60 lbs. 
of coal per hour to propel 260 cubic feet of air per second, 
at a pressure of i'2 inches of water. 

The Blackman is another form of screw fan, which has 
attained a considerable de- 
velopment for ventilating 
purposes in recent years. 

Its principle of action ap- 
pears to be that of a direct 
screw, and it is alleged that 
the partially rectangular form 
of the blade enables it to 
collect air by means of its 
edge as well as by its face. 

Hence its most efficient 
position would appear to be 

in a wall with a free space ^.^^^ ^^^ Blackman Fan Elevation. 

on the collecting side, the 

delivery for propulsion being into a channel carefully adapted 

to the size of the fan. Its maximum efficiency is stated to 





<?► 



/ 






<^^ 



f '""^n^HT A TNO '^ 



<^^ 



. \ 



Fig. II. Plan showing air currents in vicinity of indraught of Blackman 
48-inch Fan with 500 revolutions per minute. 

depend upon the delivery of air at a low pressure, as for 
instance from \ inch to \ inch on the water gauge. 



VII.] Movement of Air. 99 

In its most convenient form this fan would be worked by- 
electricity. In this case, the arrangements are such that no 
belting or driving gear is required. And the fan is its own 
motor, its periphery being the armature, its frame the field 
magnets, and the commutator occupying the place of the 
position of the usual pulley. The driving power is equally 
distributed all round the fan ; and can be easily connected 
by wires to any current available. 

In the case of the extraction of air from wards by fans 
instead of by heated flues, the observation already made as to 
inlets would apply. In the case of using the fan to propel 
air into a ward, the inlets would be similarly placed high up, 
and the outlets low down. The latter would not necessarily 
require any extracting power to be applied to them, but 
having regard to the various outlets through which the air 
from the ward might escape, some plan for extraction would 
preferably be combined with propulsion. 



H 1 



CHAPTER VIII, 



WARMING. 



Before discussing the relative advantages and disad- 
vantages of the different methods by which change of air 
can be effected in hospital buildings, it will be necessary to 
make some observations upon warming. 

Warming is essentially connected with the provision of 
fresh air, inasmuch as the large volume of fresh air wanted 
for a hospital ward in this climate could not be supplied in 
cold weather without danger to patients unless the tempera- 
ture of the wards can be adequately maintained. 

There are different qualities of heat which depend upon 
the different ways in which the heat is applied, and as these 
differences have a very important bearing on the warming 
of hospital wards, it will be as well to recall them to memory 
in this place. 

Heat is transferred from the incandescent fuel to the bodies 
which it warms by conduction, by convection, or by radiation. 

Conduction is the transference of heat from one body to 
another, by means of some tangible medium which fills the 
whole space between the two bodies. For instance, if a poker 
be held with one end in the fire, the heat from the fire is 
transferred along the poker to the hand by conduction. 

Convection is the transference of heat from one place to 
another by the bodily moving of heated substances. 

The warming of a building by hot-water pipes is an instance 
of transference of heat both by conduction and convection. 



Warming. i o i 

The heat from the fire is, in the first place, communicated 
by conduction through the plates of the fire-box, from the 
incandescent fuel to the water in the boiler. 

It is transferred by convection along the pipes which convey 
the water to different parts of the building, as the hot water 
circulates. It is again transferred by conduction to the air 
close to the pipes. This air, being expanded, ascends, and 
carries the heat with it by convection to different parts of 
the room. 

Radiation is a form of the transference of heat which is 
not either conduction or convection by ordinary matter. 
That is to say, heat which is transmitted in a manner of 
which all we know for certain is that it is not convection 
or conduction as generally understood, is called radiant heat. 
Radiant heat warms to a greater or less degree the solid 
bodies upon which the rays impinge, but practically passes 
through the air without warming it. 

Thus a blazing fire warms a person by the radiant heat 
which passes through the intermediate air to his body. In 
a homogeneous medium radiant heat is propagated in straight 
lines. 

It has hitherto been assumed that it is propagated with 
less velocity in a dense medium than in a rare one ; and 
that therefore on the top of a high mountain, when the air 
is rarefied the sun's rays are intensely hot, but when these 
rays are withdrawn by clouds, or at night, the cold becomes 
intense. 

The amount of heat radiated from a body at a given 
temperature depends on the physical nature of the surface 
of the body. If a cube be made of tin and filled with hot 
water, and one of the sides blacked and another left bright, 
much more heat will be radiated from the black surface than 
from the bright one. 

The hotter the body in proportion to an adjacent body, 
the greater proportionally will be the rapidity with which it 



I02 



Healthy Hospitals. 



[CH. 



emits radiant heat, and the emission of heat will be greater 
in direct proportion to the difference of temperature between 
the two bodies ; as for instance is shown in the following 
table : — 



Excess of Temperature 

of Radiant above that 

of Recipient in deg. 

Fahr. 


Temperature of Recipient 
in deg. Fahr. 50°. 

Ratio of Heat emitted or 
absorbed. 


432° 
306' 
216° 
180° 
126" 

55° 
18° 


2.98 
2.13 
1.69 

1-55 
1.36 
1.15 
1.07 



It may be here mentioned that ignited fuel has a tempera- 
ture of about 2300° Fahr. ; iron of a dull red 1320°, or of 
a red just visible 960°. 

In the presence of a cold body, an adjacent warm body 
will rapidly lose its heat. If a person in a warm condition 
sits near a cold wall, the radiation from the person's body 
to the cold wall will cause the sensation of a draught. 

This is easily tested by hanging a piece of carpet on the 
cold wall so as to intercept the radiation, when the feeling of 
draught will cease. 

All these considerations have an important bearing on 
the application of heat to occupied rooms. But in hospitals 
the question of warming cannot be separated from that of 
ventilation. And we cannot obtain adequate ventilation 
combined with warming without a considerable expenditure 
of money. 

Warming and ventilation in hospital wards is usually 
effected by one of the following methods : — 
I. The open fireplace in each room. 



VIII.] Warming. 103 

II. Warmed air brought into the rooms or corridors by 
flues from a centrally placed calorigen or heating apparatus. 

III. Close stoves, placed in the room or corridor to be 
warmed ; or else hot-water pipes, or steam pipes heated by 
a boiler in some central position, and carried by the pipes 
thence to the places where the heat is wanted. 

The heat conditions which prevail between the air and the 
walls or objects in a room are different in each of these cases. 

But before discussing these several methods of heating 
it will be desirable to make a few preliminary observations 
on conditions which regulate the loss of heat in buildings. 

In the first place : in determining the heating power 
required, consideration should be given to the climate of 
the place and to the position and subsoil of the building. 

In the next place : the materials and thickness of the walls, 
and the area and construction of the windows, have to be 
considered. 

The heat absorbed from a body by contact with cold air 
is not influenced by the nature of the surface, all materials 
losing the same amount, under similar conditions of tem- 
perature ; nor does the form of the body affect the result 
materially; the loss varies only with the more or less dis- 
turbed condition of the air in contact. 

But the loss of heat through walls and windows, per square 
foot per hour, will be partly by contact with air and partly 
by conduction ; in this latter case, the amount transmitted 
varies with the material of which the wall is built, and its 
thickness, for similar conditions of temperature of the 
surfaces. 

The formulae which govern this loss of heat will be found 
in ' Healthy Dwellings ' (Oxford), Box on Heat, and other 
books. It suffices here to give a general idea of the value 
of different building materials for retaining heat, and the 
conducting power of the materials, or the unit of heat trans- 
mitted, per square foot per hour, by a plate i inch thick. 



I04 Healthy Hospitals. [ch. 

The difference of temperature between two surfaces, t—t^—\ 
Fahr., is shown by the following table : — 



Iron, the units of heat transmitted are . 233 

Lead 113 

Marble (white coarse) .... 22.4 

Calcareous stone . . . . .137 

Glass 6.6 

Brick-work 4'8 

Plaster 3-8 

Double windows with glass not less than ) 

\ 3-6 
2 inches apart J 

Wood Pine parallel to fibre . . . 1.4 

„ „ perpendicular to fibre . . 0.75 

Stagnant Air 0.3 



The latter figures show the value of panelled walls, and 
also the advantage of hollow walls in which no circulation of 
air occurs. 

Loss of heat through floors : — When the floor is exposed 
to the external air, the loss of heat will be by conduction 
only, and the formulae for loss of heat through walls will 
apply, but when not so exposed this loss will be practically 
null. 

Loss of heat through ceilings : — When the ceiling is com- 
posed of brick arches, concrete or joists, lathed and plastered, 
and covered by a good roof of slates or tiles laid on board 
and felt, the loss will be very small ; but when the roof forms 
the ceiling, and is either of brick, concrete, slate, tin, glass, 
&c., the loss will be considerable by conduction, the same 
formulae applying as for walls, &c. 

Loss of heat through windows : — The above table shows 
that the loss of heat through glass would be considerably 
more than through brick-work and plaster. But the propor- 



VIII.] Warming. 105 

donate loss of heat by walls, as compared with the loss of 
heat by windows, varies with the proportionate extent of 
wall exposed to the outer air; with 14-inch brick walls, and 
an assumed internal temperature of 60° in the room, and an 
outside temperature of 30°, the proportion of loss of heat 
from wall-surface to loss of heat from window-surface may 
be approximately taken to be about i : 2-5. 

I, The open fire. 

If there is a bright fire in the room, the rays from the 
flame and incandescent fuel convey warmth to the walls and 
furniture of the room, whilst its rays leave the air to be 
breathed cool, and there is no doubt that the perfection of 
ventilation would be to have cool air to breathe, but to be 
surrounded with warm walls, floors, and furniture, so as not 
to feel ourselves parting with our heat to surrounding objects. 

Besides this, the open fire enables each occupant of a room, 
by selecting his position, to regulate according to his wishes 
the amount of heat he desires to obtain from it. 

Unfortunately, we have never succeeded in preventing the 
open fire from injuring the outside atmosphere by the smoke 
which it emits at times. 

With the open fire a proportion of the heat is used for 
producing a current in the chimney-flue, and does not warm 
the room, and hence in considering the fuel consumed in an 
open fire, we must remember that a portion of the fuel is 
being expended to assist the ventilation. Thus, for instance, 
with an open fireplace, a velocity will frequently prevail in 
the chimney of ]0 feet, and in some instances of 15 feet per 
second ; thus causing, with a flue 14 inches by 9 inches, the 
removal of from 30,000 to 45,000 cubic feet of air per hour. 
On the other hand, when the fire is low the temperature in 
the chimney falls, and consequently the velocity and volume 
of air is diminished. 

Unless provision be made for replacing the air thus 
removed, it would find its way into the room as best it can, 



io6 



Healthy Hospitals. 



[CH. 



by crevices round doors and windows, as well as through the 
walls. Hence m hospital wards special means of admitting air 
should be provided. 

Let us first consider the way in which an ordinary open 
fireplace acts to create circulation of air in a room with 
closed doors and windows. 

With an open fireplace the air is drawn along the floor 
towards the grate, it is then warmed by the radiating heat 
of the fire, and part is carried up the chimney with the smoke, 
whilst the remainder flows upwards near the chimney-breast 




Fig. 1 2. Section of Room showing movement of air. 



to the ceiling. It passes along the ceiling and, as it cools 
in its progress towards the opposite wall, descends to the 
floor, to be again drawn towards the fireplace. 

It follows from this, that with an open fireplace in a room, 
the best position in which to deliver the fresh air required 
to take the place of that which has passed up the chimney, 
is at some convenient point in the chimney-breast, between 
the chimney-piece and the top of the room, for the air thus falls 
into the upward current^ and mixes with the air of the room 
without perceptible disturbance. 

The inventions in forms of fireplaces are very numerous. 



VIII.] Warming. 107 

But except as to smoke consuming appliances (which need 
not be entered upon here) they fall under few heads. 

As already mentioned the open fire warms chiefly by 
means of radiant heat. 

Therefore, with the simple open fire, the grate selected 
should in the first place be one which contributes radiant 
heat most effectively. 

Radiant heat much depends upon a fire with flame. The 
material used for the sides and back which are in contact 
with the incandescent fuel should not absorb but should 
reflect heat. The height of the grate above the floor should 
be considered, because the fire when raised throws its rays 
upon the floor at a better angle for warming it than when the 
grate is very low or on the ground. So far as radiant heat 
alone is concerned it is difficult to improve upon the simple 
form of Rumford Grate, with splayed firebrick sides, and with 
the back arranged to lean slightly forwards over the fire, 
whilst in order to favour the draught, some air should be 
admitted through the bottom of the grate and the front bars 
should be vertical to prevent accumulation of ashes upon 
them. 

It may, however, be advantageous for small hospitals to 
have a grate with hobs for convenience of administration, 
and Figure 13 shows a fireplace on the Rumford plan, with 
hobs, used by Mr. Peach, Architect. AA are fire brick-blocks, 
BB are glazed bricks. 

In addition to radiant heat, the heating power of various 
descriptions of grates has been increased by an extended 
heating surface for warming the air which comes in contact 
with it. This extended surface is sometimes afforded by 
iron or tiled fronts, but probably the most effective form (apart 
from a ventilating fireplace) is by a warmed hearth such as 
is afforded by the radiating bars of the Sylvester grate, one 
of the ends of which terminates in the fire, and the other 
ends project like a fan into the room, and form the hearth. 



io8 



Healthy Hospitals. 



[CH. 



thus affording a large heating surface. Mr. Pridgin Teale's 
(the Lionel Teale) is a fireplace in a fire-clay receptacle below 
the level of the hearth, which latter stands about 4 or 6 inches 
above the floor level ; this grate is an adaptation of the Sylvester 




ELEVATION. 



SECT/ON. 




Fig. 13. Rumford Grate with hobs. 

grate in that it has an iron plate carrying the hearth tiles, by 
means of which they are made hot, and thus the raised hearth 
of this grate throws out considerable heat, and is also useful 
as a hob. 



vin.] Warming. 109 

With the open fire and the admission of cold air direct 
from outside, the air in different parts of the room may 
vary to the extent of 5° or 6° in temperature, and conse- 
quently sensations of draught may be experienced. 

In all open fireplaces, with a good draught, there is 
a considerable portion of the heat evolved beyond that 
utilized for warming the room, and even beyond what is 
necessary for purposes of ventilation. 

This may be used to warm inflowing air. The ventilating 
fireplace, called the Galton Grate, was designed for the War 
Office with this object^. 

Fresh air is admitted to a chamber formed at the back of 
the grate, where it is moderately warmed by a large heating 
surface, and then carried by a flue, adjacent to the chimney- 
flue, to the upper part of the room, where it flows into the 
currents which already exist in the room ; and with this form 
of grate and its ventilation the temperature of a room has 
been found not to vary in any part to a greater extent than 
1° Fahr., or at most 2°. The body of the stove is of iron, 
but the fire is placed in a fire-clay cradle ; this prevents 
contact between the lighted fuel and the iron which com- 
municates the heat to the fresh incoming air. The giving- 
off surface, obtained partly by the back of the grate and 
its flanges, and partly by the lower part of the smoke-flue, 
amounts to about 18 square feet. 

Figure 14 shows one form of this grate. 

General Morin's experiments showed that the proportion 
of heat utilized in the room by the use of warmed air in this 
grate was three times as much as that utilized by an ordinary 
grate. 

These grates are for placing in the side walls. 

Another form, in use at the Herbert Hospital, was devised 
to stand in the centre of the ward : the chimney b passes under 

^ These grates are made by Messrs. Kennard, both of Upper Thames 
Yates and Haywood, and by Messrs. Street, E.C. 



no 



Healthy Hospitals. 



[CH. 



the floor, and is placed in the centre of the flue a, which brings 
in the fresh air to be warmed by the fireplace : by utilizing 
this heat more than 0,6 superficial feet of heating surface have 
been obtained for warming the fresh air, beyond that afforded 




Fig. 14. Ventilating Fireplace. 

by the heating surface in the air-flues in the fireplace, which 
furnish from I3 to 15 feet ; Figures 15 and 15 «. 

The fire stands in an iron cradle fitted to the fire-clay back 
and sides, and a current from the air of the room is brought 
through the fire-clay at the back of this cradle, c, where it 
becomes heated, on to the top of the fire to assist the com- 
bustion, and thus prevent smoke. The top of the stove is 
coved inside, to lead the smoke easily into the chimney. 



VIII.] 



Warming. 



1 1 1 




Fig- 15- 



which passes down into the horizontal flue b under the floor. 
The main body of the 
stove is a mass of fire- 
clay, with flues a cast in 
it, up which the fresh air 
passes from the horizontal 
air-flue already mentioned, 
in which the chimney-flue 
is laid. Thus all the parts 
of the stove employed to 
warm the fresh air, with 
which the fire has direct 
contact, are of fire-clay. 

This is especially essential in hospitals, where every ele- 
ment of possible impurity of air should be avoided ; and it 
has been shown by ex- 
periments at the Con- 
servatoire des Arts et 
Metiers, that iron, and 
cast - iron especially, 
when heated to a high 
temperature, will allow 
of the passage through 
it of the carbonic oxide 
from imperfect com- 
bustion of the fuel in 
the grate : moreover, 
highly heated iron in 
contact with air may 
act on the organic 
matter, diminish the 

oxygen, and interfere Fig. 15 a. Ventilating fireplace lor Hospital. 

with the freshness of the air. 

The sectional area of the fresh-air flue with this arrange- 
ment of grate may be i square inch for every 100 feet of 




112 



Healthy Hospitals. 



[CH. 



cubic contents of the spaces to be warmed, for favourable 
situations ; but in cold or exposed localities a less area may 
be allowed. 

The horizontal chimney-flue in the Herbert Hospital fire- 
places is formed of two layers of sheet-iron, separated by 
a thin layer of fire-clay, so as to prevent overheating of the 
surface, and it is about no square inches in area. The 
horizontal chimney-flue terminates in a vertical flue in the 
side wall, which should be rather larger in area than the 
horizontal flue. This vertical flue is carried in the upper 
floors to a height of double the length of the horizontal flue, 
and is carried down to the basement, whence it can be swept. 
The points of connexion between the horizontal chimney 
with the descending flue from the fireplace, and with the 
ascending flue in the wall, are very carefully rounded, as this 
is essential to assist the passage of the smoke. The hori- 
zontal flue is swept 
from an opening, to 
which access is ob- 
tained by taking up 
a, moveable board in 
the floor, and by push- 
ing a brush along the 
flue, and thus forcing 
the soot into the ver- 
tical flue, whence it 
falls down and is re- 
moved at the opening 
jo{iK% in the basement. 

There is placed a 
spare flue by the side 
of the vertical flue, 
terminating in a fire place in the basement, which enables the 
vertical flue to be warmed, so as either to make it draw when 
the fire is first lighted, or to enable a current to be maintained 




Plain Tiles in Cement 

A A Fresh-air Flues. 
Fig. i6. Saxon Snell's Thermhydric Stoves 



VIII.] Warming. 113 

for ventilating purposes through the fireplace when the fire is 
not lighted. The portion of floor over the horizontal flue 
should be so constructed as to be taken up, in order to enable 
the air-flue to be easily and thoroughly cleaned periodically. 

Another form of grate which increases the heating surface 
and provides fresh air is Mr. Snell's Thermhydric grate, 
Fig. 16. 

In this fireplace a small boiler is placed behind the grate 
and communicates with a series of iron pipes alongside of it, 
in which the hot water circulates. These hot-water pipes are 
arranged to afford a large heating surface, over and through 
which air is admitted to the room. The grate occupies the 
centre of the room, and the products of combustion are 
carried off by a flue placed underneath the floor. 



CHAPTER IX. 

WARMING {continued). 

11. Warming by hot air conveyed along flues from a central 
source of heat. Warmed by 

{a) A furnace or iron cockle. 
{b) Hot water or steam pipes. 

There are some preliminary considerations which it will be 
desirable to notice. 

(i) Preliminary tempering of the air. When a volume of 
air has to be heated at a central source, advantage may be 
taken of the earth's temperature in very cold weather for 
tempering the air. 

At a very little depth below the surface of the earth, in all 
countries, the earth is of the average temperature of the 
climate, as may be ascertained by the temperature of springs. 
It will hence appear, that if the air which is requisite to 
supply a house in the winter of cold countries, were made to 
pass along a subterraneous cavity, it would become consider- 
ably warmed. It has been found by experiment, that a 
passage of two hundred feet in length in England has had the 
effect of warming the air of the atmosphere passing through 
it, to much above the arithmetical mean between the outer 
air and that of the earth. 

In summer the hot air could be cooled by this means. In 
using such air-flues the air should be drawn from a height of at 
least eight to ten feet above ground level ; and the impure air 
from the surrounding ground must be excluded. This could be 



Warming. 1 1 5 

adequately secured by a channel faced with glazed bricks laid 
in cement, or else by using iron pipes with properly made joints; 
small pipes would be more effectual for transferring the heat 
of the ground to the air than large ones, but with a large 
volume of air and small pipes, friction would be considerable. 
Such channels must be so arranged as to be always kept 
thoroughly clean^ where possible, light, and free from damp 
or insects, &c. In hot malarious countries this arrangement 
if adopted would require especial precautions. 

(3) Inconveniences of warming a room by means of 
heated air. 

When hot air is conveyed into a room by flues from a stove 
or other central source of heat in the basement, it is neces- 
sarily warmer than the walls, consequently the walls and 
furniture of the room are warmed by means of the heat 
conveyed to them by the heated air, and are thus necessarily 
cooler than the air itself. The warmed air is less pleasant 
and invigorating to breathe than cold air. If you take two 
equal volumes of air, one heated and the other cold, the 
expanded heated air will contain less oxygen per volume 
than the colder air. 

For instance, at a temperature of 32° a cubic foot of air weighs 
567 grains, which would be distributed in the proportion of 
4,48-8 grains of nitrogen to 11 8-2 grains of oxygen, whilst at 
a temperature of 80° the cubic foot of air weighs ^\6 grains, 
which would be distributed in the proportion of 408-4 of 
nitrogen to 107-6 of oxygen. 

It is probably for that reason that the air of a frosty 
morning is so invigorating. 

The method of warming the walls by means of the warmed 
air necessarily leaves the walls colder than the air of the 
room, and the heat of the body is radiated to the colder walls. 
Hence if the walls are to be warmed by the air admitted into 
the room, the temperature of the warmed air must be raised 
beyond what is either comfortable or healthy for breathing ; 

I a 



1 1 6 Healthy Hospitals. [ch. 

and thus if you obtain your heat by warmed air alone, 
admitted direct to the room, discomfort in one form or the 
other can with difficulty be avoided. It follows that if we 
desire to have comfortable rooms warmed with hot air, we 
ought either to have an open fire or steam, or hot-water pipes 
at a high temperature, to radiate heat to the walls, or else to 
make the warmed air pass under the floor, and through spaces 
reserved in the walls so as to warm them before it enters the 
rooms, and then we should not suffer from the discomfort of 
radiating away the heat of our bodies to cold walls ; and the 
highly heated air which had parted with some of its heat to the 
walls would pass into the room at a comfortable temperature. 
(3) Considerations affecting economy in using warmed 
air to heat a building. 

In estimating the cost of warming air, and then through its 
means transferring heat to the place where it is required, as 
compared with that of placing the source of heat itself in the 
room to be warmed, an allowance above the actual volume 
of air to be warmed must be made {a) for creating move- 
ment to propel the air through the flues, {b) for the loss of 
heat from the distance traversed by the air between the source 
of heat and the space to be warmed, and {c) for the loss of 
heat from the position of the heating surface in chambers 
where it is warmed, especially when below ground. 

As regards the latter cause of loss, when the subsoil is 
of clay, and the heating surface is placed in channels or 
chambers level with the foundations, great care should be 
taken to ensure that the drainage of the building is sufficiently 
deep to clear all water from these channels, or much loss of 
heating power will be caused, owing to the evaporation 
of the surface water which collects in different parts of the 
apparatus. 

Of course the loss of heat from warmed air passing through 
flues depends upon the form of the building. In a compactly 
built house where all the heat generated in the central 



IX.] Warming. 117 

calorigen passes into internal walls, and the area of the 
outside walls is comparatively small in proportion to the 
cubic contents of the building, this heat would not neces- 
sarily be wasted ; but in the case of a hospital, in which the 
principle of construction is, that the area of the outside walls 
should be large as compared with the cubic space, and in 
which the warmed air has to be conveyed to considerable 
distances through underground passages connecting the various 
buildings, and which afford large surfaces from which the heat 
can pass away unused, the question of loss of heat becomes 
material. 

Moreover, the calculation of the heating surface to be fixed 
in a warming chamber, when the air to be heated is put in 
motion by mechanical means, either by an aspirating chimney 
or by propellers, is a more complicated one than when the 
heating surface is fixed in the space to be warmed. 

(4) Necessity of enabling the occupants of each ward to 
control the temperature of air admitted. 

In the supply of air to hospital wards, the temperature 
at which the inflowing air enters the ward is of great 
importance. 

It is the province of the medical man to say what tempera- 
ture should be maintained in the wards. Hence where the 
warming depends on the temperature of the air, there must 
be some subsidiary means of influencing the temperature of 
the air before it enters each ward, placed under the control 
of the ward attendants^ beyond that afforded by the central 
calorigen. 

In cases where the inflowing air is admitted as supple- 
mentary to an open fireplace, a temperature of 54° to ^6° should 
generally suffice for the inflowing air. But where employed 
as the only source of warmth it should, in this country, 
probably enter the wards at a temperature of not less than 
from 58° to 64°. Indeed, some diseases, such as those of the 
respiratory organs, may require an even temperature to be 



ii8 Healthy Hospitals. [ch. 

always maintained, of probably not less than from 6'^ to 68° 
Fahrenheit, 

On the other hand, in the United States, where the climate 
is very dry, it would seem that a temperature of 70° is not 
considered excessive, and that higher temperatures are some- 
times demanded. 

The duty of the designer of the hospital is to see, first, that 
the heating apparatus or central calorigen provides adequate 
means for maintaining the prescribed temperature ; and 
secondly, that the sister in charge of the ward has it always 
in her power to modify the temperature of the air as it enters 
the ward. 

The hot-air system must also be supplemented by some 
arrangement for moistening the air at will. In temperate 
weather, if fresh cold air is arranged to be mixed with warmed 
air this moistening might not be wanted. 

When the outer air is cold and its capacity for moisture 
small, the moistening of the warmed air may, however, be 
found necessary. 

A warm-air system for hospitals must depend either on 
propulsion or on extraction. 

Air, like all other bodies, obeys the laws of gravitation, and 
is subject to those laws of inertia in virtue of which no body 
can change its state of repose or motion, except as a result of 
the forces by which it is influenced. 

And hence the warmed air must be either drawn into the 
wards by extraction- flues or propelled into them by fans or 
blowers, i. e. it must be assisted or solicited by mechanical 
means in one form or other. 

We will now consider the principal methods in use for 
warming air at a central source of heat. 
{a) Heating by Furnace or Cockle. 

The iron cockle for warming air was much in vogue 
before boilers and hot-water pipes had attained their present 
efficiency of construction, on account of its simplicity. 



IX.] Warming. 119 

The ordinary cockle may be described as an iron box ; its 
principle is to provide a large flanged surface to convey the 
heat from the fire which is placed inside to the outer air. 

The surface of a cockle will attain a temperature of 280°, 
and with a large volume of air passing over it this will not 
affect the air injuriously. 

But it has its disadvantages. It is necessarily very unequal 
in its effects. With a strong fire and a small volume of air it 
may overheat the air ; if the fire gets low the temperature 
falls rapidly, and the uniform regulation of the temperature 
of the air is not so easy as with a boiler. 

The Smead air-warmer is an improved form of cockle which, 
by affording a very large heating surface, tends to prevent 
over-heating the air ; and it thus not only utilizes very fully 
the heat from the coal, but is calculated to warm a very large 
quantity of air. 

The part of the fire-box which contains the ignited fuel is 
formed of corrugated plates by which the heating surface is 
increased. The actual fire-box is lined with an iron lining to 
prevent the fire from striking directly on the outside iron 
surfaces with which the fresh air to be warmed is in contact ; 
and this lining is arranged with openings to admit of the air, 
which is heated by contact with it, passing to the incandescent 
fuel, so as to diminish the smoke. 

There is an extension of the fire-box, also of corrugated 
plates. This is divided into two parts by vertical plates, 
and an interspace is thus formed, up which the outside air 
passes to be heated. 

A further heating surface is afforded by two horizontal 
quasi-rectangular shaped boxes, along which the smoke travels 
back from the end of the extension of the fire-box to the front 
part of the apparatus ; and it is thence conveyed to the 
chimney, which is at the back end of the fire-box, by a 
horizontal circular flue which lies between these rectangular 
boxes. 



120 Healthy Hospitals. 

The whole is surrounded by brick-work, which is built so as 
to leave a space between it and the outside of the heater. 

The fresh air impinges upon all the iron surfaces. This is 
an American invention, and certainly appears to be the most 
efficient form that has yet been arranged for heating air by 
the direct action of the fire. 

The heat of the coal is utilized directly by means of a 
cockle, and if the heating surface is sufficient to remove the 
heat from the gases of combustion, so as to allow the latter 
to pass into the chimney at as low a temperature as the 
gases in the case of a low-pressure hot-water boiler, there 
ought to be economy, and there is certainly simplicity. 

As already mentioned, impurities may pass through the 
highly heated iron of a stove or cockle into the warmed air, 
and, in any case, if a crack occurs in the joints, the fumes of 
combustion may pass into the warmed air and cause much 
inconvenience. 

This source of evil may be removed, or at any rate 
mitigated, by warming the air by means of stoves of fire-clay 
or earthenware. This material is not, however, well adapted 
for warming large volumes of air, because of the slow rate of 
conduction of the material. 

A hot-water boiler takes up and distributes the heat of 
combustion more uniformly and therefore more efficiently 
than a cockle, and as a general rule the heat of the smoke 
escaping from the boiler is less, on the average, with a carefully 
arranged boiler than that from the cockle. Therefore, even 
where the warming is by means of hot air, the air can 
generally be most conveniently warmed by hot-water or 
steam-pipes. But there is also the consideration that the 
temperature of each ward must vary with the orders of the 
physician or surgeon, and the furnace or cockle would not of 
itself afford means for supplementary heating. 



CHAPTER X. 

WARMING {con tinned). 

{h) Hot-water or steam-pipes. 

The considerations affecting hot-water and steam-pipes are 
equally applicable to pipes arranged to warm air at a central 
source of heat, or to pipes carried all round a building, and 
both these methods may therefore be conveniently discussed 
together. 

Hot-water pipes for warming air are free from many of the 
objections arising from the direct application of heat to iron, 
because the heat can be regulated with exactness. 

Water boils at 212° Fahrenheit under the atmospheric 
pressure of 14-7 lbs. per square inch, or 30 inches of 
mercury, i.e. at about the sea-level. Under one-half that 
pressure, viz. 7-3 lbs. per square inch, or 15 inches of 
mercury, it boils at 180°; and under a pressure above 
the ordinary atmospheric pressure, of 45 lbs. per square inch, 
it boils at 292° ; and under a pressure above the atmosphere, 
of 175° lbs. per square inch, it boils at 377° Fahrenheit. 
Thus a high temperature may be obtained from water 
without generating steam by heating it under pressure. 

Steam is generated under the mean atmospheric pressure of 
30 inches of mercury when the boiling-point is attained, i. e. 
sj 2° ; but before the water becomes vapour a further amount 
of heat equal to 966° is absorbed and becomes latent ; this 
would have sufficed to raise the water to 1178°, if it did 
not turn into steam. The temperature of 1178°, which is 



122 Healthy Hospitals. [ch. 

thus required to produce steam, is necessarily constant, and 
consequently a greater or less amount of heat becomes latent 
according as the pressure is below or above the atmospheric 
pressure. This latent heat is given out on the reconversion of 
steam into water. 

There are certain general conditions affecting hot-water and 
steam-pipes which it will be well to recapitulate here. 
Hot-water pipes. 

The question of using hot-water pipes at a low temperature, 
or hot-water pipes under pressure, as in Perkins' system, or 
steam-pipes for warming the air at a central source of heat, 
is almost entirely one of convenience of application and 
conditions of economy. 

The considerations which apply are — i. Heat is emitted 
and absorbed in an accelerating ratio, in proportion as the 
difference of temperature increases between the body from 
which the heat is radiated and the body which receives the 
heat. And with the same difference of temperature between 
the recipient and the radiant, the effect of the radiant will be 
greater according to the increased temperature of the re- 
cipient ; ixi other words, the ratio of the emission of heat 
increases with the temperature. That is to say, pipes heated 
by hot water under high pressure convey heat to the air 
with greater rapidity than pipes heated by hot water at low 
pressures ; and steam-pipes are more effective than hot-water 
pipes ; and steam at a high-pressure is more effective than low- 
pressure steam. 

It would, therefore, seem that the most economical way of 
supplying heat to the large volume of air required for the 
supply of a hospital, would be either by high-pressure hot- 
water or steam-pipes. 

2. But there is another consideration. Pipes at a low tempe- 
rature give out their heat to warm the air, but they give out 
very little radiant heat to warm the walls ; on the other hand, 
pipes at a high temperature like high-pressure hot-water pipes 



X.] Warming. 123 

and steam-pipes give out a considerable amount of radiant 
heat to warm the walls, as well as direct heat to warm the air 
in contact with them. Therefore, in an air-chamber in which 
fresh air is warmed, the high-temperature pipes radiate their 
heat to surrounding surfaces, and in that way afford an in- 
creased heating surface for warming the air. 

3. The temperature of the pipes can be varied in the case 
of hot-water pipes, both at low and high pressure, by a modi- 
fication of the fire in the furnace ; with steam this is not so 
simple, but where a large heating surface is concerned, it 
would probably be found preferable to vary the temperature 
of the inflowing air by exposing more or less of the heating 
surface rather than by varying the heat of the fire. The 
whole body of fresh air would in this case be heated to a 
moderate normal temperature at the central source of heat, 
and then subsidiary pipes would be provided under each ward 
which could be applied or not to give extra warmth to the air of 
the ward at the will of the attendant. The amount of heating 
surface required to maintain the temperature of the main body 
of air might have to be varied according to the temperature 
of the outer air. This would be effected by some simple 
method of exposing more or less of this heating-surface to the 
inflowing air, according to the temperature of inflow required. 

In the House of Commons, batteries, as they are called, con- 
sisting of numerous parallel flanges, are placed at intervals on 
the steam-heated pipes and thus create heating surface ; and 
an attendant is constantly employed to cover with thick cloth 
or uncover one or more of these batteries, according to the 
extent of heating-surface desired to be exposed to the air. 
This arrangement renders it unnecessary to alter the heat in 
the pipes themselves or in the furnace. The plan already 
described by Mr. Key for the steam-pipes for warming the 
air in the Victoria Hospital in Glasgow fulfils the same object, 
and is well suited for controlling the heat of the general body 
of air in a hospital. The plan is to arrange the pipes in 



124 Healthy Hospitals, [ch. 

sections ; one or more of which can be heated as desired. 
These sections are covered by a series of shutters of non- 
conducting material, of which one or more can be opened or 
closed at will ; these prevent the fresh air from passing over 
the hot pipes or allow it to do so as desired, and the heating- 
surface which is exposed to the inflowing air can be thus 
varied accordingly. The volume of air passing in is not 
altered, because a corresponding bye-pass is opened at the 
same time that any shutter covering the hot pipes is closed, so 
as to allow cold air to pass in, instead of the air warmed by 
the pipes. 

Each ward must be provided with a subsidiary set of hot- 
water or steam-pipes, so arranged that their heating -surface 
might be wholly or partly exposed to, or shut off from, the 
inflowing air for the regulation of the temperature of that 
entering the wards. The arrangement for this purpose in the 
Johns Hopkins Hospital is shown in Figure 25, page 161. 
The original plan of the building should include all the 
arrangements for warming and ventilating, and the hot-water 
engineer or the steam-fitter should commence his work in a new 
building at an early period of its construction. 
Low-pressure hot-water pipes. 

The efficiency of hot-water pipes depends upon the circula- 
tion of water in the pipes, in which the motive power is the 
difference in weight between the column of water ascending 
from the boiler through its top outlet, or flow-pipe, and that 
returning to the boiler through its bottom inlet, or return-pipe. 
As the water in the boiler is heated it expands, becomes lighter 
and ascends to the top of the boiler in the direction of the 
flow-pipe, and is replaced by colder and consequently heavier 
water from the bottom or return-pipe ; this in turn gets heated, 
ascends, and is replaced by more cold water from the return- 
pipe, and this circulation continues so long as the fire is kept 
up ; the hot water continually ascending, and the cold water 
descending. The efficient action of hot-water pipes depends 



X.] Warming. 125 

upon the upward flow of the heated and expanded water, as it 
passes from the boiler, being made as direct as possible, and so 
protected as to lose little heat between the boiler and the place 
where the heat is to be utilized. The return-pipe, which brings 
back the water to the boiler after it has been cooled down by 
the abstraction of heat in warming the air, should be passed in 
to the bottom of the boiler as directly, and in as uniform a 
line from the place where the heat has been used, as possible. 

However, in all cases the fire should be as near to the 
bottom of the ascending column as possible; when quite at 
the bottom a short column will suffice to produce the neces- 
sary motion. 

The quantity of heat which the water in the pipes can 
convey to the air will depend upon the velocity of flow in the 
pipes. 

The velocity of flow in the pipes depends on the difierence in 
weight of the two columns of water, which would be obtained 
from the specific gravity of the water at the temperature 
at which the water leaves the boiler and that at which it 
passes down the return-pipe back to the boiler, and the 
height to which the heated water has to rise. 

The efficiency of a hot-water apparatus will be regulated by 
these conditions, by the sizes of the pipes, and by such other 
conditions as affect the flow of water in pipes. 

It will be evident that to obtain an equal velocity of flow 
when the height of the vertical column is small, the tempera- 
ture at which the water returns to the boiler must be lower 
than when the vertical column is long. Therefore, when the 
boiler or source of heat is very near the level of the pipes for 
heating the air, the average temperature which can be obtained 
in the pipes will be lower than when the vertical column is 
long. Hence, the heating-surface of the boiler^ the area of the 
grate which regulates the flow of air to the fuel, and the surface 
of pipe which enables the heat from the boiler to be utilized, 
must be regulated with reference to this difference of level. 



126 Healthy Hospitals. [ch. 

It may further be assumed that with small pipes, the 
temperature being constant, the velocity of flow in the pipe 
necessary to furnish a given amount of heat will vary as the 
ratio of the length of the pipe. 

When the water circulates through the pipes by virtue of the 
difference of temperature of the flow and return-currents only, 
it is impossible to count upon a greater mean temperature in 
the pipes than from i6o° to i8o°, because above that tempera- 
ture the water in the boiler begins to boil, and causes an 
overflow of the supply-cistern and escape of steam at the air- 
pipes. In order to obtain a sufficient velocity of circulation 
for long distances, or with small differences of level, a forced 
circulation may be resorted to, as has been done by Messrs. 
Easton and Anderson at the County Lunatic Asylum at 
Banstead. 

Here two pipes are laid side by side, one of which commu- 
nicates with the boilers, and is termed the flow-pipe ; the 
other, termed the return-pipe, is connected with the feed- 
cistern for the boilers, which cistern is situated above the level 
of the boilers. 

Both pipes are connected with the various coils, to which 
the heated water is desired to be conveyed, by valves which 
can be opened or closed at will. An Archimedean screw 
pump is fixed on the return-pipe, near the point where the 
pipe ascends into the cistern. This pump is always kept 
at work. When the communications between the flow and 
return-pipes are closed, the screw simply slips through the 
water ; as soon as any communication is opened, the screw 
draws the water along the pipe and forces it into the cistern, 
thus ensuring a constant circulation. 

For calculations as to the sizes of boilers, length and 
diameters of pipes, and similar practical details, the reader 
is referred to Hood, Box, and other authors ^. 

^ Mr. Hood gives the following surface exposed to the direct action 
rule, that one square foot of boiler of the fire, or 3 ft. of flue surface, 



X.] 



Warming. 



127 



High-pressure hot-water pipes. 

By Perkins' system the water is heated under considerable 
pressure, and a higher temperature is thus obtainable than 
with ordinary pressure. 

In its simplest form the apparatus consists of a continuous 
or endless iron tube of about one inch diameter, closed in all 
parts and filled with water. About one-sixth part of the tube 
is coiled in any suitable form and placed in the furnace, form- 
ing the heating surface, and the other five-sixths are heated by 
the circulation of the water which flows from the top of this 
coil ; the water after having been cooled in its progress through 
the pipes, returns to the bottom of the coil to be re-heated. 
The heat attained in the pipes depends upon the length of tube 
exposed to the fire as compared with the length carried round 
the building. 

Water when heated from 39° to 212° Fahr. expands about 



would heat 40 ft. of 4-inch pipe. 
To find the length in feet of iron 
pipe required for heating the air in 
a building, — multiply the volume of 
air in cubic feet, to be warmed per 
minute, by the difference between 
the temperature in the room and 
the external temperature, and mul- 
tiply by 1. 1 2 for 2-inch pipes, by .75 
for 3-inch pipes, by .56 for 4-inch 
pipes, and divide the product by 
the difference between the internal 
temperature and that of the pipes. 

The same authority gives the 
general rule that the length of 4-inch 
pipe required to warm a room may 



be calculated by dividing the cubic 
contents of the room, in feet, by the 
divisor 150, in order to maintain a 
temperature of 60° Fahr., and that 
3-inch pipes require to be one-third 
longer, and 2-inch pipes require to 
be double the length, of 4-inch 
pipes, to heat the same number of 
cubic feet, but this rule does not 
take into account the volume of air 
required in hospitals. 

The following table from the 
same authority shows approximately 
the quantity of coal used per hour 
required to heat 100 feet in length 
of a 4-inch pipe and 2-inch pipe : — 



Diameter of Pipe 
in inches. 


Difference between the Temperature of Pipe and Room 
in Degrees Fahr. 


4 

2 


ISO 


125 


100 


80 


4.7 lbs. 
2.3 lbs. 


3.9 lbs. 
1.9 lbs. 


3.1 lbs. 
1-5 lbs. 


2.5 lbs. 
1.2 lbs. 



128 Healthy Hospitals. [ch. 

5 per cent, of its original bulk. Therefore, in order to provide 
for the increased volume of the water when heated, a tube 
called an expansion-tube, proportioned in size to the quantity 
of tube to which it is attached, is placed above the highest 
level of the tube which conveys the heat to the distant parts 
of the building. 

The filling-tube of the apparatus is placed on a level with 
the bottom of this expansion-tube, so as perfectly to fill all 
the small tube, and yet prevent the possibility of filling the 
expansion-tube itself. The expansion-tube being then left 
empty, allows the water as it becomes heated to expand 
without endangering the bursting of the smaller tube. 

The apparatus is filled by pumping water into an opening 
connected with the lowest level of tubing, so that the water, as 
it rises, drives the air before it, and out through an opening 
in the expansion-tube. Great care must be taken to expel 
all air from the pipes by repeatedly forcing water through 
them. When the pipes are filled, both the opening in the 
filling-tube and the opening in the expansion-tube are closed 
by screw-plugs. 

The form and size of the furnace varies according to the 
locality and the work the pipes have to do. A temperature 
of as much as 300° Fahr, is sometimes arranged to be obtained 
in the tubes. 

Steam-pipes. — Steam in lieu of hot water is especially 
applicable, either where steam for other purposes is in use, as 
for instance where the exhaust steam from an engine is 
available, or where heating is required on a large scale. 

So far as economy in heating is concerned, there is not 
much difference between the use of exhaust steam and that of 
steam taken direct from the boiler. 

Steam-heating may be either on what is termed the high- 
pressure system or the low-pressure system. 

The high-pressure system of steam-heating is generally 
considered to mean the system which allows the steam to 



X.] Warming. 129 

escape after use or else to be passed into a feed water-tank, 
whence it has to be pumped back into the boiler. 

The low-pressure system is considered to mean the system 
in which there is a flow-pipe from the top of the boiler for the 
steam, and a return-pipe into the bottom of the boiler for the 
water of condensation, so arranged as to require no pumping. 

A low-pressure gravity system of steam-heating is probably 
the most economical and convenient form of steam-heating 
appliance : as it is equally applicable to heat a single room or 
a large building. Its principal merits, when well done, are : 
it is safe ; noiseless ; the temperature of the heating-surface is 
moderate and uniform ; all the water of condensation is 
returned into the boiler, except a very small loss from the 
air valves ; it is easy to keep the stuffing-boxes of the heater- 
valves tight ; and it is no more trouble to manage than a hot- 
water apparatus. 

With a high-pressure system the waste of heat is some- 
times enormous with traps which discharge into an open tank, 
or into the atmosphere. The difference in favour of a gravity 
apparatus working properly, with direct return -traps, can 
always be estimated at 15 per cent., over apparatus which 
permits the water to escape, and thus either loses it, or 
utilizes it by pumping it back : and when traps are neglected 
(which is the rule), it may reach 30 per cent, of all the heat. 

The general principle of the low-pressure form of steam 
service is that the steam should rise direct from the boiler 
into the main distributing pipe, and that this pipe should 
always have an incline downwards, so that all condensed 
water should run to the lower end, where it is passed by a 
relief-pipe into the return-main ^ (see Fig. 17). By this plan 
the steam and condensed water always flow in the same 
direction, and this is a great safeguard against noise. 

The application of steam to a building requires to be done 
by an engineer thoroughly skilled in steam-heating. 

^ See Baldwin on Steam Heating. 
K 



I30 



Healthy Hospitals. 



[CH. 




X.] 



Warming. 



131 



It may be useful to observe that the heat necessary to warm 
a pound of water at mean temperature (39° Fahr.) one degree, 
that is one heat unit, will warm 3^ pounds of air one degree. 

The heat necessary to convert one pound of water from the 
temperature of feed- water, or return- water, at 178°, to steam 
at one pound pressure (or to any pressure not noting the sh'ght 
increase for high-pressures), is 1,000 heat units, and this will heat 
48,000 cubic feet of dry air one degree ; or 4,800 cubic feet of 
air 10 degrees ; or 480 cubic feet of air 100 degrees, making 
no allowance for the expansion of the air, which will increase 



700 










































fi.sn 










































600 








































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700 
6£0 
600 
550 
£00 
4-50 
400 
360 
300 
250 
SOO 
150 
ICO 
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Difference ofx^ 20° 30° 40° so° 6o° 70° ao" 30° ido° 110^ 120° ii3o°Ko°i50°i6o° no'iao'iadzoo'TeTn-perahire. 
TenvpertibuTe oJAir 60° 

Fig. 18. Units of heat from cast-iron and wrought-iron pipes. 



the bulk i\ for a difference of loo degrees ; in other words, 
the 480 cubic feet will be increased to 583 when heated 100 
degrees, and the 4,800 will be increased to 4,930 or -^-^ of its 
bulk for a rise of temperature of 10''. 

The annexed Figure 18, resulting from Mr. Anderson's 
experiments, is published in the Journal of the Institution of 
Civil Engineers for 1877, and shows the total units of heat 
given out by cast-iron and wrought-iron pipes, per square foot 

K a 



132 Healthy Hospitals. [ch. 

of surface, per hour, for various differences of temperature, 
applicable either to hot-water or steam-pipes. 

Suppose, for example, it is required to know how much 
heat will be given out by 4-inch pipes at 190° in a room, the 
temperature of which is 60°, the difference of temperature 
being 130° : look along the line of abscissae for 130°, and the 
ordinate then gives 23a units for 4-inch pipes, and '3,^6 units 
for 2-inch wrought-iron pipes per square foot per hour. 

These data and those in the foot-note on p. 1 26 are merely 
mentioned to give a general idea of the effect of pipes. But 
for purposes of calculation the reader is referred to Box on 
Heat, to Hood, Baldwin on Steam-heating, and Hutton's 
'Works Manager's Handbook,' and other authorities whose 
names will be found in the list appended to this volume ^ 

HI. Warming by heat acting in the wards either (a) by 
close stoves or {b) by hot-water and steam-pipes. 

Preliminary remarks. — Although these methods are in many 
respects materially different, they yet present certain conditions 
which may be conveniently considered together. 

^ A rough approximate rule for Manager's Handbook,' gives the 

pipes heated with exhaust steam following rule : — 
has been given by Mr. Boulton, Heating Rooms by Steam at 

who has largely used exhaust steam 212° Fahr. 

as follows : — i superficial foot of A I -horse-power boiler is suffi- 

steam-pipe for each 6 superficial cient for 48,000 cubic feet of space, 

feet of glass in the windows ; I To heat a room to 60° F. the length 

superficial foot of steam-pipe for of steam-pipe may be found by the 

every 6 cubic feet of air removed following rule — To find the length 

for ventilating purposes per minute; in feet of steam-pipe, multiply the 

I superficial foot of steam-pipe for volume of air in cubic feet, to be 

every 120 superficial feet of wall, warmed per minute, by the dififer- 

roof,orceiling, allowing about 15 per ence of temperature in the room 

cent, on the amount thus obtained and the external temperature, and 

for contingencies. He states that, divide the product by 304 for 4-inch 

roughly speaking, the exhaust steam pipe, or by 228 for 3-inch pipe, by 

due to one-horse power can be 152 for 2-inch pipes, and by 76 

made to warm 30,000 cubic feet of for i-inch pipe, 
space. In neither case is due allowance 

Mr. Hutton, in 'The Works made for ventilation. 



X.] Warming. 133 

Stoves or pipes warm the air in contact with them, and give 
out a proportion of radiant heat, which passes to the walls 
and furniture of a room, dependent upon the degree of heat 
to which they are warmed. 

Thus with ordinary low-pressure hot-water pipes, the 
temperature of which rarely exceeds from 120'' to 130^, the 
larger proportion of the heat acts to warm the air of the 
room, and the air warms the walls and furniture. 

But when stoves or pipes are heated to a high temper- 
ature, the heat is partly communicated to the adjacent 
air, and partly acts as radiant heat to warm the surface 
adjacent. 

This will be best explained by imagining a stove-pipe 
heated at the end nearest the stove to a dull red heat of 
1230° Fahrenheit, and of sufficient length to allow the heat 
to be diminished to 150° at the further end. 

It would then be found that at the stove-end of the flue- 
pipe, 92 per cent, of the whole heat emitted by the pipe is 
given out by radiation to the walls, and only 8 per cent, to 
the air ; but at the exit end the heat is nearly equally divided, 
the walls receiving ^^ and the air 45 per cent. 

Taking the whole length of such a pipe, the walls would 
receive 74 per cent, and the air 26 per cent, of the heat 
emitted. 

With flue-pipes heated to lower temperatures the air might 
receive much more than half the heat. 

When, therefore, the object is to heat the walls of the 
room, rather than the air, the temperature of the pipes should 
be high. 

For instance, with the Perkins' system of small pipes and 
closed circulation, the temperature of the pipes may vary 
from 150° to 250° or even 300°. With these latter more than 
half the heat would be radiated to the walls. 

With low-pressure steam-pipes the heat will vary from 
about 230° to 180°, and with high-pressure steam-pipes as 



134 Healthy Hospitals. [ch. 

much as 300° to 400° may be obtained, and with both these 
much heat is radiated to the walls. 

Thus the character of the heat which we desire to obtain 
must decide the form of heating, and the temperature to be 
maintained in stoves or pipes. 

With warm walls and floors and furniture the air must be 
comparatively cool for comfort, or we should not be able to 
part with our heat at a sufficient rate ; on the other hand, if 
the walls are cold we must have a hotter temperature in the 
air, to prevent the heat of our bodies being parted with too 
rapidly, but comfort is greater when warmth in the walls and 
floors is combined with cool air to breathe, as for instance, 
air at a temperature of 54° to 56°. 

In considering the economy of these various methods of 
heating, it may be observed that with hot-water or steam- 
pipes a proportion of the heat generated by the fuel is applied 
to effect mechanical motion in the water or steam, and does 
not therefore appear as heat in the room ; on the other hand, 
the non-conducting covering of the pipes should prevent the 
loss of any heat by the radiation from the pipes which might 
occur between the source of heat and the ward or place where 
it is utilized. 

With a close stove in the room all the heat generated by 
the fuel, except a small proportion lost up the chimney, passes 
into the room. 

(«) Close stoves placed in the Wards. 

As a rule the close stove does not assist ventilation. If of 
iron, it may allow carbonic oxide to pass into the ward ; if of 
tile, its temperature would be too low to afford radiant heat to 
the walls. 

The most economical and probably the most perfect form 
in which stove-heating can be applied is the old German 
stove, or at any rate some modification of it. But it is limited 
in its application, and unless very large the fire-clay cannot 



X.] Warming. 135 

give out sufficient heat to warm a large body of incoming air. 
Its economy depends upon its not being combined with the 
admission of fresh air through internal flues in the stove ; 
when the heat is so extracted the expenditure in fuel is 
necessarily increased. 

Moreover, a stove of fire-clay with a tile-surface is a more 
hygienic way of applying heat to air than an iron stove in 
which the fire is in contact with the iron, mainly because of the 
risk of gases from combustion passing through the iron. 

A stove with a fire-clay lining which shields the iron 
covering from the direct action of the fire, but allows the 
iron to warm the air, affords a safe way of applying heat 
to air. 

The simple iron-stove, if heated to a very high temperature, 
might supply a large proportion of heat to the walls of the ward, 
but such a high temperature might injure the air ; on the other 
hand, low-temperature iron and other stoves only heat the air, 
which in its turn warms the walls. 

All these methods of heating have the inconvenience of 
requiring the fuel to be brought into the ward, as is the case 
with the open fire ; but they have not the advantage which the 
open fire has of supplying radiant heat, and of largely pro- 
moting the extraction of air from the ward. 

A gas-stove is not a satisfactory form of heating for a 
hospital ward ; the fumes are comparatively low in tempera- 
ture, hence the draught they produce in the chimney is small, 
and they are therefore liable to pass back into the ward. 

(b) Hot-water or steam-pipes fixed in the locality to he heated. 

These may be used, as already mentioned, either in con- 
nexion with the open fire, or again, where warmed air is also 
supplied ; or they may be applied as the only source of heat. 

The selection of the method of heating the pipes will 
depend upon the local circumstances. 

In the case of a large hospital, where steam-boilers are 



136 Healtfiy Hospitals. [ch. 

required for providing power for lifts, laundry work, &c., and 
where an engineer or artificer would be at hand, steam-pipes 
would probably be found the more convenient and economical 
method. 

In the case of smaller local hospitals, it might be preferable 
to use hot-water under pressure or otherwise, which would not 
require skilled attention. 

The low-pressure hot-water pipes, which do not convey heat 
to adjacent cold surfaces, have the tendency to cause the 
deposit of dust, therefore those pipes, such as high-pressure 
hot-water or steam-pipes, which are at a temperature which 
enables them to radiate heat to and warm the adjacent 
objects, would seem preferable, on the ground of cleanliness, 
to low-pressure hot-water pipes. But the low-pressure hot- 
water pipe which does not contribute much heat to warming 
the walls, might therefore be preferably used in connexion 
with the open fireplace, whose action is to warm the walls. 

In a hospital ward it is preferable that the heat should be 
uniformly diffused along the walls ; therefore it is better to 
lay the pipes along the walls without radiators, which collect 
the heat at certain points. It would also be advisable, as 
a means of equalizing the temperature of the walls, to carry a 
portion of the pipe-surface near the floor-level, and a portion 
round the upper part of the walls above the level of the 
windows, so as to distribute the heat more uniformly. 

All heating-pipes in a ward should be laid above the floor 
level, exposed to view, with sufficient space between them 
and the floor or wall to enable dust or dirt to be easily 
removed. 

A uniform distribution of heat over the whole floor of the 
ward, without the inconvenience of pipes exposed to view, 
has been effected by placing steam-pipes under a floor 
made of marmor terrazzo, and so warming the whole floor. 
Supplementary heating in this case might be applied by 
an open fire, or as has been provided in the instance under 



X.] Warming. 137 

consideration by steam radiators, standing like stoves in the 
centre of the ward, through which fresh air is passed and 
warmed before it enters into the ward. In no case should a 
ward be warmed by pipes in the floor so laid as to admit of 
any communication between the ward and the channel in 
which the pipes are laid. For in that case the channel would 
only become a receptacle for dirt. 

It is also an axiom that pipes for heating purposes should 
be entirely separate from pipes for the supply of hot water. 



CHAPTER XI. 



LIGHTING. 



Day Light. — Light and particularly sunlight maintains the 
purity of the atmosphere and exerts an important influence 
on vitality. It is essential for the organic development of 
plants and animals : and on the other hand, sunlight, and 
especially the actinic rays of the spectrum, has been shown 
to kill some classes of spores and bacilli and to check the 
development of certain forms of micro-organisms in connexion 
with disease. 

The absence of light seems to be one of the contributing 
causes of the low health and deformities often prevailing 
amongst the children of the poorer classes in towns, which 
is diminished if not removed by their exposure to light and 
fresh air in the country. 

But independently of this, light is required in hospitals 
as an antagonist to dirt. Dark corners mean dirt, because 
dirt must be seen to be removed. The absolute cleanliness 
which is essential throughout a hospital can only be obtained 
where a flood of light is directed to every part of the 
building, as much under staircases^ in closets, and in cup- 
boards, as in the wards themselves. 

So far as work or reading is concerned, it may be assumed, 
according to Dr. Forster^, 'that the most perfect ease in 
reading, or in fine work, is felt in the open air on a summer 

^ See Willoughby's ' Hygiene and Public Health.' 



Lighting. 139 

day when the sky is overcast. Under these circumstances 
the light is ample, but it is perfectly diffused, there is neither 
glare nor shadow, and the light may be said to come from 
all sides, but from no one in particular.' 

But it is an axiom that direct sunlight should penetrate 
into a room occupied by the sick. Hence the conditions 
required for light necessarily affect the shape of the hospital 
wards. 

An East and West aspect for a hospital ward, which has 
windows on opposite sides, allows of this permeation of sun- 
light at some period of every day on which the sun shines. 

Independently, however, of the question of direct sunshine 
the light should as far as possible come from the sky, and 
no part of a room can be deemed sufficiently lighted from 
which a certain amount of sky cannot be seen. 

This affects both the question of the level of the upper 
part of windows as well as the proximity of buildings. 
Dr. Forster of Breslau laid down as a rule that the arc of 
sky visible from any part of a room should not be less 
than 5°. This seems somewhat small for a hospital ward, 
but if the height of the ward is made equal to half its width, 
if the windows are carried up to within about a foot from 
the ceiling, and if the adjacent buildings are placed at a 
distance equal to twice their height measured from the level 
of the ward floor, this proportion of sky illumination would 
be more than obtained, and, indeed, with windows of adequate 
size placed on both sides of a ward the light would be 
abundant. 

Artificial light. — Every form of matter, when sufficiently 
heated, has the power of emitting rays of light, and thus 
becomes self-luminous. 

This condition is termed incandescence. 

All artificial sources of light depend upon the development 
of light during incandescence. In every ordinary flame we 
recognize two things, light and heat. But they are very 



140 Healthy Hospitals. [ch. 

different ; the one depends upon the amount of incandescent 
matter diffused throughout the flame, the other upon the 
amount of matter oxidized or burnt in a given time. 

A flame, that of a candle for example, structurally consists 
of two hollow cones, the inner of gases and matter going up 
to be burned, the outer of burning matter and of incandescent 
particles diffused through it. 

For the purposes of lighting our streets and houses we 
have hitherto chiefly made use of a combustible gaseous 
combination of carbon and hydrogen which forms the chief 
constituent of ordinary coal gas. When this hydro-carbon 
burns, that is to say, when its elements unite with the 
oxygen of the air, it undergoes partial decomposition, the 
hydrogen unites with the oxygen, and forms water, and 
heat is evolved. The carbon is separated in the solid state, 
and floats in a finely divided and incandescent state in the 
interior of the burning vapour, and this constitutes the 
flame. The presence of the particles of carbon may be 
easily shown by holding a non-combustible body in the 
flame, when the carbon, in fine powder, will be deposited upon 
it, forming a layer of soot, or what we generally term lamp- 
black. The combustion of the particles of carbon takes place 
at the border of the flame, where they are first brought into 
contact with the oxygen of the air, when these substances 
unite and form carbonic acid ; but if the supply of oxygen 
to them be insufficient in quantity, they partly go to form 
carbonic oxide, which is a highly deleterious gas. Moreover, 
a portion escapes into the air of the room as solid particles, 
the result of which is that the flame is said to smoke. 

The brightness of the flame is owing to these solid incan- 
descent particles. The burning gas itself possesses only a 
feeble illuminating power. 

The Bunsen burner gives a smokeless and non-luminous 
flame. In the Bunsen burner ordinary gas is conducted into 
the tube of the burner, but at the same place air enters, and 



XI.] Lighting. 141 

mixes itself with the gas in the interior of the tube ; and thus 
oxygen is admitted, not only to the border of the flame, but 
throughout its whole mass, and the carbon is accordingly 
burnt into carbonic acid before it can separate in the solid 
form, so that the flame is composed of incandescent gases 
alone, and gives a very feeble light, and deposits no soot on 
bodies held in it. 

If a solid body be introduced into this feebly luminous 
flame, such, for instance, as a piece of platinum wire, the 
incandescent metal glows with a brilliant light ; and this fact 
has been utilized to produce the Welsbach and other similar 
forms of incandescent light. 

The flames of candles and lamps, whether the substance 
burnt be tallow or wax, rape or petroleum, do not differ 
essentially from those of an ordinary gas-burner. The same 
hydro-carbon gas, which is the essential constituent of common 
gas, is the source of light in them. 

The hot wick, which draws up by capillary attraction the 
fluid material about to be burnt, plays the part of a small 
gas factory, the produce of which is used on the spot^ the 
only difference being that coal-gas is always purified before 
it is consumed, whereas the extemporaneous gas of a candle 
or lamp is consumed without being purified at all ; on the 
other hand, the tallow, wax, and oil contain the carbon and 
hydrogen in a purer and more concentrated form than the 
coal from which ordinary coal-gas is made. 

The flames of candles and of lamps all owe their luminosity 
to the incandescence of particles of carbon floating in them ; 
and the reason why one description of candle or lamp is 
more smoky than another is because the supply of air in 
the smoky one is not sufficient to produce adequate 
combustion. 

From this it is obvious that in order to obtain the highest 
illuminating power of a flame in which hydro-carbonaceous 
compounds are undergoing combustion the regulation of the 



142 Healthy Hospitals. [ch. 

supply of air is essential. This more perfect combustion is 
also essential to the maintenance of the purity of the air of the 
room. 

In a hygienic aspect, it is also essential that the compounds 
used to produce light should be as pure as possible ; and 
during the last twenty years vast improvements have taken 
place in the methods of purifying gas, so that now the 
London gas is almost entirely free from sulphur and its 
compounds. 

The effect caused on the air of a room by combustion is 
(ist) to diminish the oxygen, and (2nd) to increase the car- 
bonic acid and to produce water and ammonia. If the 
combustion is imperfect, the effect is also to create carbonic 
oxide and soot, as well as to disperse into the room any 
impurities which the material used for illumination contains, 
besides the carbon and hydrogen which are necessary for 
purposes of illumination. 

The standard which has been adopted for light is that of a 
No. 6 sperm candle burning 120 grains per hour. 

Illumination consists of two factors, candle-power and 
distance. 

The candle-foot, that is, the illumination produced by one 
standard candle at a distance of i foot, may be taken as the 
unit of illumination. 

The candle-foot is a very convenient and ' comfortable ' 
illumination. It is, for most people, the best illumination for 
reading, and is to be found on most well-lighted dining- 
tables. More than 1 candle-feet is seldom attained in artificial 
illumination. One candle at i foot is equivalent to 4 candles 
at 2 feet, and 9 candles at 3 feet. The illumination produced 
by a i6-candle lamp, at a distance of 8 feet, is only 0-25 
candle-foot. 

The following table affords a general comparison of the 
effects of the combustion of different materials employed 
for purposes of illumination upon the air of a room in 



XL] 



Lighting, 



14: 



producing one candle power ; but the form of the wick and 
burner would modify the actual figures. 





Quantity 
Consumed. 


Carbonic acid 
produced. 


Water 
Vapour. 


Units of 
Heat. 


Tallow . . . 
Sperm , . . 
Oil 


Grains. 

120 
91 


Cubic feet. 
•51 
.41 

■11 


lb. 
•023 

■020 

.018 


97 
79 
72 


Gas — Cubic feet 


5.6 


.40 


.025 


121 



Oil gives out light with the least injurious effect on the air 
of a room. For the same amount of light, gas throws out 
the largest amount of impurity and also produces the largest 
amount of heat ; the conditions are, however, altered by the 
use of regenerative burners. 

Independently of this, the hygienic conditions in the burning 
of gas differ somewhat from those in the case of candles. 

The gas comes from a street main, in which the pressure is 
constantly varying, partly in consequence of the continual 
variation which takes place in the number of lights in use. 

With increased pressure much unconsumed gas may be 
forced through the burners, and this is of itself highly injurious 
to breathe, especially for the sick. 

Indeed the leakage of unconsumed gas through burners 
when not in use is a reason not to place a gas-burner in 
a bedroom. Gas, in hospitals especially, is not safe without 
the use of some form of regulator. The efficiency of regu- 
lators is much affected by differences of pressure, hence it is 
preferable that each floor of a building should have a separate 
regulator. 

The fumes from gas may under favourable conditions be 
utilized to assist ventilation, by being led into exhaust 
ventilating flues, but unless there is some motive power in 



144 Healthy Hospitals. 

the flue independent of the heat from the gas, the fumes 
are liable to return into the room. Gas contributes warmth 
to a room in addition to light, and for this reason is much 
appreciated by the less well-to-do classes of the community. 

The electric incandescent light, formed by a thread of 
carbon, rendered incandescent by means of an electric current, 
and contained in a closed vessel out of any contact with the 
atmosphere, can in no way vitiate the air of a room, and is in 
fact the most hygienic form of light which can be imagined. 

On the other hand, the arc electric light, which is not con- 
tained in a closed vessel, may be injurious to health in an 
occupied space because of the nitric acid developed. At the 
same time it must be borne in mind that the arc light, 
combined with artificial heat from hot-water pipes, will 
develop the growth of plants, produce flowers, and ripen 
fruit. May not, therefore, the same qualities in its light 
furnish curative influences on sick persons ? 

The electric light cannot be modified or turned low as a 
gas light can. With the incandescent electric light an 8-candle 
power light is probably the most convenient size to adopt in 
a ward. The lights should be distributed so as not to con- 
centrate glare at any one point ; the globes should be pre- 
ferably frosted, and each light should be arranged to be 
shaded when desired. Every bed, or each pair of beds, should 
be furnished with an attachment into which the wires of 
a moveable light can be inserted, so that full illumination 
at any patient's bed may be afforded to the nurse or doctor 
when desired. 



CHAPTER XII. 

SOME OF THE METHODS IN WHICH THE BEFORE-MENTIONED 
PRINCIPLES HAVE BEEN APPLIED IN HOSPITALS. 

Having thus explained the general principles which govern 
the movement and the warming of air, we now proceed to 
make a few remarks upon some of the methods by which 
these principles have been applied in practice. 

It will be convenient to adopt the same classification as 
before, viz. 

I. Simple natural ventilation by windows and fireplaces, or 
by stoves in the wards, assisted by additional inlets and out- 
lets, the effect of which is dependent on natural movement 
of the air. 

3. Mechanical extraction of the air from the ward, supple- 
mented by the provision of fresh warmed air to take its place. 
(a) By aspiration. 
(d) By propulsion. 

I. Ventilation by windows and fireplaces, or by stoves in the 
wards, assisted by additional inlets and outlets. 

This is the general system in use in temperate climates, 
such as England, apparently because the climate is so variable. 
Whilst we' may occasionally in winter have weather as cold 
as in Germany or the United States, it does not last, but 
a milder temperature generally prevails, which the warming 
must be continually varied to suit. 

The convenience of this system lies in the fact that each 

L 



146 Healthy Hospitals. [ch. 

ward is self-contained as to its ventilation. The simplest 
form of this plan is, when in small and old-fashioned hospitals 
the fireplaces depend for inlets on the windows only, by- 
means of a broad bottom bar on the lower sash of the 
window, so that the window when raised affords a vertical 
inlet along the middle bar and avoids making an opening 
at the bottom of the window, which would cause a draught 
on the patients ; or else one of the window-panes may be 
converted either into a Moore's ventilator or into a hopper 
ventilator. 

Another arrangement is for the window to be divided 
into three parts, of which the upper part is made to fall in 
and form a hopper ventilator, whilst the two lower divisions 
are made either like an ordinary double-hung sash window, or 
like a French casement window, in which latter case almost 
the whole window opening can be utilized for admitting 
fresh air. 

Inlets are also made independent of the windows. For 
instance, Sherringham ventilators are placed near the ceiling 
or midway between ceiling and floor, or vertical tubes with 
openings at 5 o^' ^ feet above the floor may be used, but 
these latter are objectionable, as affording convenient recep- 
tacles for the collection of dirt ; openings just above the 
floor-level are sometimes adopted, which afford a useful 
means of occasionally sweeping out foul air from under beds, 
but these are unfit for continuous use because air thus ad- 
mitted gives a sensation of cold to the feet both of nurses 
and patients. 

The number of days in the year on which windows can be 
kept open in this climate is considerable. 

With windows open on opposite sides of a room, and with 
a moderate movement of the atmosphere outside blowing 
across the building, air would enter the open window at 
one side, and would be extracted at the other side. The 
volume of air which would pass through the building by 



XII.] Methods Applied in Hospitals. 147 

means of each pair of opposite windows, as well as that 
which passes through the walls, would amount to at least 
from 500,000 to 700,000 cubic feet per hour. 

With a hospital ward which is arranged for one window to 
every four beds, this would afford some 120,000 to 180,000 
cubic feet per hour per patient ; and this would be a change 
of air difficult to arrange by any method of purely artificial 
ventilation. 

On days on which the windows cannot be kept fully open, 
and when a fire is lighted, the chimney-flue forms a powerful 
extraction-shaft to assist the movement of air. 

The fireplace is preferably placed in the centre of a ward, 
as it distributes thence its rays more equably. 

If placed in a side wall, and if there are two fireplaces in 
the ward, it would be preferable for the movement of the 
air currents which the fireplaces generate, that both should 
be on the same side ; but, on the other hand, for distributing 
the rays of heat to the walls they would be preferably on 
opposite sides. 

In a circular ward three fireplaces placed round a central 
chimney would probably afford radiant heat to the whole 
wall-surface. 

The change of air by means of open fireplaces depends 
upon the current in the chimney-flue ; this is strong when 
there is a good fire. 

In military hospitals an additional means of extraction is 
provided by vertical shafts carried from the room to above 
the roof. When these shafts are combined with fireplaces 
in winter ventilation they should invariably be carried from 
the floor-level to above the roof But it is convenient to 
have them arranged with a valve, so that if desired in 
summer they may be used to remove the air from the 
ceiling-level, as shown in Figure 23 (page i57)j because, in 
summer when the fire is not lighted and windows are much 
opened, extraction might advantageously take place at the 

L a 



148 Healthy Hospitals. [ch. 

upper part of the ward. All such shafts should preferably 
be straight and vertical, i.e. without bends, which create much 
friction. They should be of such a size that a moderate 
upward current may produce an adequate removal of air ; 
and the movement of outside air will rarely afford a less 
movement in the shaft than 3 or 4 feet per second. If one 
were allotted to every two beds, a shaft 9 inches square at 
the low velocity of 3 feet per second (corresponding to a 
movement of the outside air of about 3 miles per hour), 
would remove a volume of air amounting to 2,000 cubic feet 
per hour. This, with the additional effect of the open fire 
in a ward of 20 beds, would be to cause the removal of at 
least 3,000 cubic feet per patient per hour. And with ade- 
quate inlets for air, accompanied by properly arranged shafts, 
a continuous and generally adequate ventilation would pre- 
vail, which might, however, require occasional supplementing 
by opening windows. 

It may be here observed that the plan which is frequently 
adopted by architects of placing the fireplace in the centre 
of the ward and carrying up the flue directly through the 
ceiling, and thence utilizing it to warm a flue or chamber for 
assisting the extraction of air from the ward ceiling, is not 
recommended. 

Firstly, it applies the extracting power of the heated flue 
much less efficiently than if the inlet for extraction were on 
the floor-level, because with equal temperatures in the 
flue the draught in a heated flue largely depends on the 
height of the warmed flue. 

Secondly, a consideration of the method mentioned in 
a former chapter, by which a fire causes air currents to 
circulate in a room, shows that any part of the chimney- 
breast above the fire is the worst place from which to effect 
the removal of air from a room. 

With the extraction of the air at the floor-level, the 
admission of air, exclusive of windows, should not be placed 



XII.] Methods Applied in Hospitals. 149 

lower than at least halfway between floor and ceiling, and 
the inflowing air should be directed upwards. 

But the inlets should be arranged to admit air also at the 
floor-level, for summer ventilation, or for occasionally sweeping 
air out of the ward. 

With the large volume of air moved out, and of air ad- 
mitted to replace it at the outside temperature, it is necessary 
to provide in hospital wards for some amount of warming 
besides the open fire. 

In some hospitals this is effected by warming a portion of 
the incoming air, by means of a ventilating grate. 

But in a large ward this will not suffice in cold weather. 
The use of low-pressure hot-water pipes is found to be a 
satisfactory adjunct to an open fire up to a certain point, 
because the radiant heat from the open fire warms walls and 
furniture. 

But the fire does not shine on all parts of the ward, and 
consequently, to assist in warming the walls, a convenient 
arrangement is to have either high-pressure hot-water pipes 
or low-pressure steam-pipes carried round the outer walls 
of the ward. 

Thus in Burnley Hospital, which is heated by steam, there 
are three rows of steam-pipes carried round the ward, 
each of a different size, so that the heating power can be 
varied either by using each pipe separately or any combina- 
tion of the three pipes. By this means the temperature of 
the wards can be easily regulated at will from inside the 
ward, and although in this hospital fireplaces round a central 
flue entered into the original design of the hospital, they have 
not been used. 

A better distribution of heat would be for two-thirds of 
the heating surface, i. e. two of the pipes, to be carried just 
above the floor-level, and one-third, or one of the steam- 
pipes, to be carried round the upper half of the ward, just 
above the windows or the upper inlets for air. 



ISO 



Healthy Hospitals. 



[CH. 




?> 




w 



% 



f 



¥^ 








tifl 




XII.] Methods Applied in Hospitals. 151 

The radiant heat from the high temperature of the pipes 
would thus distribute warmth over the walls and would 
prevent the feeling of draught from the incoming cold air. 
These pipes should be under the control of the ward sister, 
so that the regulation of the temperature of the ward would 
be self-contained. 

In other cases the steam-pipes instead of being exposed 
in the wards have been applied to warm the floors of wards. 

Warmed floors were used by the Romans : the plan is 
described by Vitruvius and may be seen in the ruins of 
Roman villas and baths. 

Warmed floors were applied in a small hospital in Switzer- 
land by a French architect, Jager, and have been recently 
adopted in the Hamburg Hospital, built by the architect 
W. F. Dencke in 1889. 

The arrangement is based on the principle of keeping the feet 
warm and the head cool. It would not conveniently be applied 
to other than buildings of one story, and it is incompatible 
with a wooden floor. The warmed floor is constructed as 
follows : — Upon a layer of cement concrete, about 6 to 9 inches 
thick, to cut ofi" all communication with the earth, are formed 
ten longitudinal channels, separated from each other by walls 
in which are openings at intervals to allow of a community 
of air between the channels. This is shown in the basement 
plan, Fig. 19, and the sections, Figs. 21 and 33. These channels 
are about 3 feet high and 3 feet wide ; they have a carefully 
cemented and tiled bottom and are covered with rectangular 
slabs of cement about \\ inch thick, which are supported for 
greater strength on iron supports. These slabs are afterwards 
carefully jointed with cement and covered with a thin layer 
of cement concrete upon which is laid the floor of the ward. 
This is made of Marmor Terrazzo (i. e. pieces of marble let 
into cement mortar). 

In these channels, about 3 inches from their upper covering, 
one or more steam-pipes are carried along each channel 



Healthy Hospitals. 




[CH. 



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XII.] Methods Applied in Hospitals. 153 

supported on iron brackets let into the walls ; the pipes are 
on the low-pressure system of steam-heating, and are so 
inclined as to allow of the water of condensation to pass 
through a return pipe back to the boiler. These channels 
have no connexion with the outer air or with the air of 
the wards ; access is obtained to them through iron doors 
opened only when required for repairs. 

The general plan of the ward itself with its appurtenances 
is shown in Fig. 20. 

Instead of fireplaces or stoves there are two radiators in 
the ward heated by steam from the boiler ; these radiators 
are unconnected with the underground channels or pipes. 
Fresh air is brought to them from the outside in ducts which 
pass under the heating channels but do not communicate with 
them. 

The removal of air is effected by means of a ridge outlet 
along the whole top of the ward which is regulated by 
valves. 

The bath-room floor is warmed similarly, but its arrange- 
ments are independent of those for the ward floor. 

The single wards and the w. c. are warmed by steam pipes, 
but the floors of these are not warmed. 

The steam boiler is under one of the single wards in a 
basement, and is managed without communication with the 
wafd floor. 

The warmed floor prevents any effluvia remaining in corners 
or under beds, as all air in contact with the floor is kept in 
movement by the warmth. And this system of floor- warming 
has the advantage that it permits of the use of a perfectly 
impervious clean floor, which is free from the difficulties of 
wooden floors ; these advantages can with diflficulty be ob- 
tained in any other way. Such a floor should however be 
kept scrupulously clean ; otherwise effluvia would pass up- 
wards from it into the air of the ward. Indeed the con- 
sideration occurs whether it might not be well to combine 



154 



Healthy Hospitals. 



[CH. 




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■-2 6 






T3 >; 



XII.] Methods Applied in Hospitals. 155 

a warmed floor with removal of air from the floor-level 
between the patients' beds. 

With the open fireplace warmed air from a central calorigen 
is sometimes used for the air supply of the wards. 

As an instance of one of the earliest methods by which 
fresh warmed air was systematically applied in this country to 
hospital ventilation, the plan adopted by Mr. Sylvester for the 
original Derby Infirmary, built about 1810, may be mentioned. 

The method adopted was to combine propulsion with 
extraction, both by natural means, upon the principle of the 
windsail of a ship's hold. The extraction was effected by 
flues carried up in the walls from the floor-level ; the passage 
of air through these flues depended partly upon the difference 
between the inside and outside temperature, and partly upon 
the movement of the atmosphere ; these flues from all the 
rooms were concentrated into a turncap above the roof, which 
was kept always turned away from the wind by means of 
vanes. The flues had openings for winter use at the floor- 
level, which were closed in summer, and openings for summer 
use at the level of the ceiling, which were closed in winter. 

The propulsive force to assist the inflow of air was ob- 
tained by a turncap placed upon a tower at some distance 
from the building in an exposed situation, with the opening 
always kept turned by vanes towards the wind. The air was 
thus forced down the tower by the movement of the wind ; 
and it passed through an underground passage, some 200 feet 
long, to a cockle in the basement of the hospital, where it was 
warmed and passed into the wards at a level between the 
height of the patient's head and the ceiling. 

It may be mentioned that although the surface of this 
cockle was heated to 280° Fahrenheit, it was stated that it 
was not found to injure the air, apparently because of the 
large volume of fresh air which passed rapidly over its surface. 
The open fire was retained to assist extraction. 



^56 



Healthy Hospitals. 



[CH. 



There were many ingenious and complicated arrangements 
in the old Derby Infirmary; but their control passed into 
the hands of a subsequent generation which did not under- 



HamOurg Hospital 

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stand them and led to disaster. The moral to be drawn is 
that simplicity in the long run is the great element of safety 
in a hospital. 

This system was identical in principle with that of General 
Morin, only it used the movement of the atmosphere for 



XII.] 



Methods Applied in Hospitals. 



157 



extraction instead of artificial heat. A plan similar to that 
of General Morin and Mr. Sylvester is in use in the United 
States, namely that of Mr. Smead, which uses artificial heat 
instead of the wind force as the 
motive power in the flue for ex- 
traction of air, and an improved 
form of cockle already described 
for warming the inflowing air. 

The Smead system has also 
been applied in combination with a 
Blackman Fan, instead of heat, for 
obtaining motive power for the air. 

The change of air in hospital 
wards by natural means was also 
made use of by Dr. Bohm (of 
Vienna). He combined ventilation 
with the German stove in the 
Rudolf Stift on the same principle 
of extraction as the flues in military 
hospitals. 

He trusted for his ventilation to 
the windows and to the difference 
of the inside and outside tempera- 
ture, as well as to the outside move- 
ment of the atmosphere. He pro- 
vided for the admission of air by 
tubes which were carried from an 
opening into the open air at the 
floor-level to the upper part of the 
ward ; there was an opening to the 
ward at the floor-level as well as 
one at the upper part of the ward ; 
it being arranged that one should be closed when the other 
was open. 

Fig. 23 shows Dr. Bohm's arrangement for inlet flues. 




Fig. 23. Inlet flue for fresh 
air arranged to admit air either 
at floor-level or at ceiling-level 
as desired. Rudolf Stift (Dr. 
Bohm). 



158 



Healthy Hospitals. 



[CH. 



The air entered the flue from the outside at the level of the 
ward floor ; and by means of valves, of which one was at the 
floor-level and the other just below the ceiling-level, the air 

was either allowed 
to pass directly into 
the ward near the 
floor, or it was di- 
rected upwards so 
as to pass in near 
the ceiling. 

In summer, when 
the stove was not 
used, the lower 
opening for the ad- 
mission of air at the 
floor-level was kept 
open. In winter, 
when the stove was 
in use, the lower 
opening was closed 
and the upper open- 
ing kept open. 

For the extrac- 
tion of air, Dr. Bohm 
carried a flue from 
the floor-level to 
above the roof; this 
flue had openings 
into the room at the 
floor-level as well as 
under the ceiling. 
Fig. 24 shows the 
arrangement by which the lower valve at the floor-level could 
open and the upper valve near the ceiling close, and vice versa. 
In summer, when there was no fire, he opened the upper 




Fig. 24. Extraction-flue arranged to extract air 
either fr<im floor-level or from ceiling-level as desired. 
Rudolf Stift (Dr. Bohm). 



XII.] Methods Applied in Hospitals. 159 

opening and closed the lower one, so as to allow the heated 
air to escape at the top of the ward. 

In winter, when the stove was lighted, he caused the upper 
opening to be closed and the opening at the floor-level to be 
opened, and the extraction was effected as it is in the open 
fireplace, from near the floor-level. The stove, a large porcelain 
one, fed from the corridor outside, maintained the temperature 
in the wards. 

Similarly the Toilet system, with its ridge ventilation, 
depends on natural extraction. 

The Hamburg Hospital, also with its warmed floor and 
ridge openings, is similarly largely dependent on natural 
means for change of air. It is the simplicity of the system 
which recommends it for use in this country, where atmo- 
spheric conditions are favourable. 

2. Mechanical extraction of air^ supplemented by a supply 
of warmed fresh air. 

(a) By aspiration. 

The simplest form of mechanical extraction is the open 
fire. But what is alluded to in the present case is the 
extraction of a definite regulated quantity of air, by means of 
flues led to a shaft in which a current is produced by the appli- 
cation of heat, and its replacement by a similar, quantity of 
warmed air when necessary to keep the temperature within 
a defined range. This extraction of air should go on con- 
tinuously day and night, winter and summer. 

In the face of a regulated extraction of air, the windows 
ought not to be opened, because it will be apparent from the 
remarks already made that the effect of open windows might 
be to seriously check the outflow of air through the extraction- 
flues, as well as the inflow of warmed air ; although open 
windows would effect a far greater change of air in the ward. 

The fireplace would be abolished, because the more 
powerful extraction-shaft, acting on all the outlets, would 



i6o Healthy Hospitals. [ch. 

tend to diminish the velocity in the smaller chimney-flue of 
the open fire, and might make it smoke, unless the chimney 
of the open fire was carried into the extraction-flue. 

But the system is practically an extension of the system of 
the open fireplace, that is to say, the extraction-flues remove 
the air from the lower part of the ward, and the fresh warmed 
air is admitted above in the upper half of the ward. 

The remarks on movement of air show clearly that whilst 
a fan may be advantageous for removing air in special cases 
and for occasional use, as in theatres or schools, yet that where 
a continuous large extraction is required day and night, as 
in a hospital, it will best be effected by the aspiration of 
a chimney-flue as proposed by General Morin, Sylvester, 
-Sir Joshua Jebb, and others. 

An adequate system of aspiration, with hot air introduced 
above and the foul air extracted near the floor-level, has been 
shown by General Morin and others to produce an equable 
temperature over the whole room. 

Surgeon-General Billings of the United States Army men- 
tioned an experiment in the Barnes Hospital, Washington, 
where fresh-air inlets for warmed air were placed near the 
ceiling and extraction outlets in the floor. 

In this experiment it was found that when warm air was 
admitted near the ceiling there was a difference of io° in the 
temperature between the floor and the ceiling, and that the 
patients complained of cold feet and discomfort. This case 
is mentioned because it is clearly an instance of the failure to 
keep the air in an adequate condition of circulation owing 
to the absence of sufficient aspiration. 

Surgeon- General Billings also remarks that when the warm 
air is introduced near the ceiling it is impossible to vary the 
temperature at different beds, a thing which it is often 
desirable to accomplish in a hospital. 

The necessity which may often arise for rapidly altering 
the temperature is indeed another consideration in connexion 



XII.] 



Methods Applied in Hospitals. 



i6i 




ELEVATION 



SECTION. 



Fig. 25. 



M 



1 62 Healthy Hospitals. [ch. 

with the supply of warmed air from a central source of 
supply. 

In the Barnes Hospital, Washington, already alluded to, the 
fresh incoming air is warmed by coils at the foot of each upcast 
shaft leading to the ward. 

The supply of hot water to each coil is admitted at will 
through a valve, so that the temperature of each coil and 
consequently of the air can be regulated. But this plan does 
not seem sufficiently rapid for a hospital; it is stated to 
require nearly an hour for the coil to cool down to the 
extent that it is sometimes desirable should occur in a few 
minutes. 

Mr. Key's system at the Victoria Hospital at Glasgow 
effects a more rapid change of temperature. 

The change of temperature in the wards of the Johns 
Hopkins Hospital can also be effected rapidly. In that 
hospital fresh air is brought to the wards from an outside 
opening about 3 feet above the level of the ground, down 
through a coil of steam-pipes placed in the basement under 
each pair of beds. Fig. 25 shows this arrangement in plan, 
section, and elevation, as described by BiUings. 

When warmed the air then passes up to the ward through 
grated openings under each window. Dampers in the coil- 
chamber enable either hot or cold air to be admitted in 
greater or less quantity through the heating-pipes, so as to 
regulate the temperature at which it enters the ward, and thus 
an almost immediate alteration of temperature can be effected 
by persons in the ward. Aspiration-flues in the floor under 
the foot of each bed, and others in the ceiling, draw off the 
ward air into a chimney which is about 60 feet high, and 
obtains its warmth from the steam apparatus, furnace, &c. 
The end bay-window is warmed by steam pipes under the 
window just above the floor-level. 

Figs. 25, 26 and 27 illustrate this arrangement. 

Fig. 26 shows a plan of one of the ordinary ward units 



CII] 



Methods Applied in Hospitals. 



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of the Johns Hopkins Hospital ; each of which, except as 
regards cooking and general administration, may be said to 
form a complete hospital in itself. 

The ventilating pipes under the floor are shown by the 

M 2 



164 



Healthy Hospitals. 



[CH. 



short dots. The ventilating pipes in the attic are shown by 
the long dots. 

Fig. 27 shows a section of the building explaining how 
the air is led into the main ventilating shaft. 

From what has already been said in previous chapters on 
warming, it is clear that warmed air supplied to a ward from 



— Johns Hopkins ! Hospit al — 




"^FEEJ 



Part Longitudinal Section 

Fig. 27. 



a central supply should be passed into the ward through flues 
in the walls, so as to allow the walls to derive some heat from 
the warmed air before it enters the ward. 

When the flue is in the outside wall the side of the air-flue 
facing the outer side of the wall would allow heat to pass 
away unused into the outer air. This loss would be best 
diminished by making the flue semicircular and exposing 



XII.] Methods Applied in Hospitals. 165 

the larger portion of the side of the flue to the ward, and 
protecting the side of the flue nearest to the outer face of 
the wall by a closed air-cavity which would enormously 
diminish the loss of heat. 

The striking feature of recent hospital construction is the 
introduction of simplicity of form. 

In the United States, in Germany, and also in France, the best 
examples of modern hospital construction have treated each 
large ward, with its subsidiary small wards and other appur- 
tenances, as a separate hospital unit on one floor, and in 
most cases detached. This renders a combined system of 
ventilation and warming for the whole establishment more 
difficult and less economical ; but each ward unit is simple 
to construct and is self-contained. 

The Johns Hopkins Hospital is an instance in point, but 
there, although the separation of ward units is a principal 
feature of the design, simplicity of arrangement in the ward 
unit itself seems to have been somewhat overlooked. 

In some hospitals the extraction of air by shafts has been 
supplemented by propulsion in the introduction of fresh air. 

Thus the Barnes Hospital at Washington is an instance of 
propulsion for fresh air, combined with extraction by heated 
upcast aspiration-shafts. This is applied in the winter only, 
the summer ventilation being by open windows. 

Fresh air is supplied by a shaft 8 feet in diameter and 
38 feet high, placed 74 feet west of the building. 

This shaft is connected with a brick air-duct, which passes 
beneath the basement through its entire length. 

At the point of junction of the vertical shaft with this fresh- 
air duct, is located the fan. This fan drives the air along the 
main duct into branch channels, leading to the coil-chamber, 
from whence the fresh-air flues are carried into the wards. 

The removal of foul air by aspiration is effected by two 
chimneys in the administration building, which are warmed by 
iron flues from the boiler and other furnaces ; and to promote 



1 66 Healthy Hospitals. [ch. 

aspiration when the boiler is not at work a separate fire is 
arranged. The foul-air ducts from the wards are led into the 
chimney-shafts. 

The aspiration system, although very simple and efficient, 
has not obtained any extensive adoption in hospitals in this 
country, partly from the fact that the arrangements for its 
due action are necessarily much interfered with by the opening 
of windows, which of themselves produce an inflow and out- 
flow of air from ten to twenty times as great as any artificial 
extraction can pretend to give. 
{b) By Propulsion. 

Methods of propulsion of air for hospital wards are based 
on one common principle, namely, that the air is to be moved 
from a central position, from which it has to be conveyed 
in air-trunks, subdivided into branches, and finally admitted 
into the rooms at such points as may be determined on. 

These methods generally provide for the egress of foul air 
from rooms so ventilated by means of foul-air shafts. 

Two examples in use forty years ago, of the method of 
ventilation by propulsion, are those of Thomas and Laurent 
at the Hospital Lariboissiere at Paris, and the plan of Dr. 
Van Heecke in the Hospitals Beaujon and Necker at Paris. 

These plans may be briefly described as follows : — That 
of Thomas and Laurent consisted of two 15-horse power 
high-pressure engines, with fan-blowers attached, to be used 
alternately in case of accident to one. The air from the 
blower was conducted along the arched basement of the 
hospital, in which the machinery was placed, by means of 
a large plate-iron pipe, from which branches were given 
off to the different buildings, these branches being again 
sub-divided to convey air to the wards. As the air-flues 
passed under the floors, sufficient space was left between the 
floor and the ceiling of the room below for an air-trunk 
T4 inches deep. The fresh air was admitted to the wards 
through pedestals 4 and 5 feet high, in the middle of the 



xir.] Methods Applied in Hospitals. 167 

floors, and the foul air escaped by openings close to the floor, 
one between every two beds, which openings communicated 
with flues in the walls, carried up to the roof of the building. 
The loss of force in driving air by means of a fan through 
a series of narrow and frequently bent tubes involves a serious 
outlay. Dr. Van Heecke's plan had the merit of greater 
economy. The form of his fan was better proportioned to 
its work, and by an ingenious provision the pitch of the screw 
used by Dr. Van Heecke was made to adapt itself to the 
velocity of the engine, an arrangement by which the air- 
current was maintained at one uniform strength ; and at the 
Hospital Beaujon the air was propelled by a small steam- 
engine in the basement directly up through the centre of 
the wards, by a tube passing through the floors of each 
superimposed story, and left to find its way out. 

In some other foreign hospitals propulsion is also resorted to. 

In the Antwerp Hospital in summer the windows only 
are used, but the diameter of the ward, 61 feet 6 inches, is 
very large for ensuring thorough ventilation, and there is 
further a serious central obstruction to the movement of air. 
In winter fresh air is propelled into the wards by means of 
fans situated in the laundry building ; this air is warmed 
by being passed over coils of hot-water pipes contained in 
a chamber situated in the basement under the central portion 
of each tier of wards, and the air so heated is propelled into 
the wards at the upper parts of the central columns. 

In the Menilmontant Hospital the warming and ventila- 
tion is effected by propulsion. Fans drive the air through 
subways from a central point ; these subways run beneath 
the various corridors of the buildings to the basements of the 
pavilions, in each of which there are placed coils of steam- 
pipes, enclosed in casings through which the air passes ; it 
becomes heated by impinging against the steam-pipes, and 
is carried up vertically through flues in the walls, and dis- 
charged into the wards through ornamented pedestals which 



1 68 Healthy Hospitals. [ch. 

are placed on either side of the entrance doors. There are 
also additional inlets formed by the projecting jambs of the 
fireplaces. These are ordinary fireplaces with large open 
grates. 

The removal of the foul air from the rooms is through 
outlet openings at both the level of the ceilings and the 
floors, which communicate with vertical shafts that ascend 
in the outer walls into channels running longitudinally 
along the centre of the roof to a chamber that is heated 
by hot air, for the purpose of further inducing an upward 
current; and it is discharged through the sides of \S\q fikhe 
surmounting the roof of the building. 

In the New York Hospital propulsion is used both for 
supplying fresh and removing foul air. The hospital is 
built in the centre of the city. It is five stories high and 
contains 163 beds. 

In the wards there is one window to each bed, each 
external pier of the building being a flue, which is lined 
with hollow bricks, to prevent, as far as possible, loss of 
heat by radiation. Through the centre of these flues run 
cast-iron pipes, intended to be fitted so as to be air-tight, 
through which fresh air is forced into the building by a fan. 

The spaces outside these fresh-air iron pipes are the foul-air 
flues. These terminate above in pipes leading to an exhaust 
fan, placed at the top of the centre building. The heating 
is by steam, the coils being arranged at the bottom of the 
fresh-air pipes in such a way that the cool air from the 
propelling fan can be sent by a valve either through or 
around the heating coil. The fresh air is admitted to the 
wards through slits in the window-sills, forming a jet directed 
upward. 

The openings for the exit of foul air from the wards are 
in part placed in the walls of the piers and in part beneath 
the beds. 

The principle of placing fresh-air pipes inside of the foul- 



XII.] Methods Applied in Hospitals. 169 

air ducts is objectionable, and on a par with placing water- 
pipes in sewers, for although the fresh air-pipes are of iron, 
and may have been tightly fitted, it is only a question of 
time when some communication will be established between 
the inner and outer surfaces of these pipes, either by rusting 
or by alternate expansions and contractions, and then the 
foul air may be carried back into the wards. The iron pipes 
are not moreover easily accessible, enclosed as they are in 
the brick walls, and there is no ready means of determining 
their condition. 

There are peculiar difficulties to be overcome in attempting 
to secure a satisfactory distribution of air in a lofty hospital 
of many stories. While the resources of modern engineering 
are, no doubt, competent to secure satisfactory ventilation in 
a hospital of even ten stories high, if necessary, this can only 
be done at a comparatively great cost, and it is therefore 
now generally admitted that it is best to put hospitals where 
they can have plenty of room without being compelled to go 
upward in order to obtain fresh air. 

A method of ventilation by propulsion is in use, as already 
mentioned, in the Victoria Hospital, Glasgow, where it is 
combined with purification or washing of the air. 

It has been applied by Mr. Key and is the most recent 
application of the principle of propulsion to a hospital in this 
country. 

It is unnecessary to repeat the arrangement adopted by 
Mr. Key for the purification and warming of the air ; it will 
suffice to take up the description after the air has passed 
the air-tempering appliances. Two air propellers of the 
Blackman type collect the air and propel it forward through 
the main air-ducts leading to the administrative block and 
to the wards. The fans have been in use for 'x\ years, for 
23 to 24 hours daily, and are worked by two electric motors 
supplied by power from the laundry engine. These fans, 
which can be worked separately (or conjointly if desired), drive 



lyo ' Healthy Hospitals. [ch. 

the air into the main ducts, which are about 5 feet high by 
3 feet 6 inches wide. These ducts pass under the centre of 
the wards, and from them horizontal ones are carried to the 
outside wall. On each side, from these horizontal ducts, 
shafts of about 4 feet by 6 inches are carried by the side of, 
or in, the outside wall vertically up to the inlets provided in 
the wards. 

Secondary heating-coils are placed at the base of the 
several shafts leading to the inlets in the wards, which can be 
used or not, as desired, by the persons in charge of the ward, 
and by this means the temperature of the air of each different 
ward can be varied at will to suit the orders of the medical 
man or the requirements of the ward sister. 

The air forced into the wards is under a pressure of ^V to 
Y^o of an inch of water column. 

The size of the main ducts under the wards should be such 
as to allow a person to pass along them ; and the preferable 
arrangement would be that these main ducts should be 
carried close to the outer wall on either side, in order that 
each ward inlet might be supplied by a subsidiary duct 
leading vertically up from the main duct ; by this means 
the condition of cleanliness of every part would be capable 
of being examined at any time. 

If therefore the inlets are in the outside wall, it would 
be advisable to have a duct on each side of the ward next 
the wall. 

There is, however, no valid reason why the inlets should 
not be raised by means of half-columns placed along the centre 
line of the wards, with the outlets on the floor level in the 
walls. 

The flues which lead to the inlets are either formed in the 
side walls or placed within the structure close against the 
side walls. The inlets are arranged to deliver the air vertically 
upwards at about 5 feet to 5 feet 6 inches from the floor. The 
air is warmed or cooled as may be desired. It passes away 



xii.] Methods Applied in Hospitals. 171 

by ducts within the structure of the walls, opening into the 
ward just above the floor-level. These ducts are led up to 
the roof, where they are all collected into a square turret 
with louvred sides standing well above the roof; the louvres 
consist of hanging valves made of cloth, six inches deep. 

These valves open outwards the full width of the frames, 
and are thus at all times available for the air to escape. 
Even in tempestuous weather, or during a gale, the outward 
flow is never interrupted, for while the valves are closed on 
the side of the cupola exposed to the influence and pressure 
of the wind, and prevent the wind from entering, those on 
the lee side are under no such pressure, the air passing out 
uninterruptedly. 

The theory of propulsion when supplemented by shafts 
is based upon the assumption that the air will come in at 
defined inlets, and will similarly have its exit at defined 
apertures, and upon this assumption the opening of windows 
would entirely derange the condition of the supply. 

Therefore Mr. Key urges that the use of windows for the 
admission of fresh air is incompatible with the system of 
ventilation by propulsion ; and that in fact with this system 
windows must be kept closed and reserved only for light. 

If there were an open fire the pressure of air in the ward 
would increase its draught. But its retention would not be 
logically consistent with this system of ventilation. 

The system of propulsion for hospital ventilation has not 
found general favour with hospital architects or managers in 
this country. There is one very patent and valid reason, 
which is that in this climate windows can be kept open : and 
when windows are open the volume of fresh air which passes 
through a ward will be at least 30 times greater than either 
the theoretical 3,000 cubic feet per hour, or even the 5,000 
or 6,000 cubic feet, which some of these systems profess 
to furnish, without entailing the large expenditure of fuel 
necessary for moving a large volume of air. For even at 



172 Healthy Hospitals. [ch. 

3,000 cubic feet per bed a ward of 20 beds will require some 
600 tons of air to be pumped into it in 24 hours. 

Indeed experience would seem to justify the hesitation 
which has been felt with respect to artificial ventilation. The 
following quotation from the Report of the Barracks and 
Hospital Improvement Commission explains this partly : — 

' In one hospital we examined, which was ventilated by 
one of the most perfect apparatus we have anywhere seen, 
and which professed to supply between 4,000 and 5,000 cubic 
feet of air per bed per hour, we found the atmosphere of 
the wards stagnant and foul to a degree we have hardly 
ever met with elsewhere. We at once pointed out this 
circumstance. An inquiry was immediately instituted, when 
it appeared that one of the valves of the supply pipe had 
been tampered with, for no other reason, that we could 
perceive, except to save fuel by diminishing the quantity of 
warm air supplied to the sick. The ventilation in this case 
was worse than a delusion.' 

The writer has visited on several different occasions three 
of the important hospitals in Europe and the United States 
of America in which the ventilation depended on propulsion, 
and on every occasion the propulsion happened to be out of 
use for the time ; in some cases evidently with the object of 
saving the expense of fuel. 

Methods of artificial ventilation are more or less dependent 
upon careful training in the assistants, they may answer well 
when first put into operation, but the arrangements, in their 
simplest form, present some complications and require some 
special knowledge for their efficient working. Hence the 
changes in personel which necessarily take place in the course 
of time may introduce want of appreciation or of care in the 
management : moreover, the continuous cost of working 
presses upon the resources of voluntary hospitals. The more 
the question is examined, the more advisable does it appear 
to adhere to simplicity in all details of hospital construction. 



xn.] Methods Applied in Hospitals. 173 

As regards the opening of windows, it may be observed 
that the author visited a hospital recently in which the 
ventilation was by propulsion. The amount of fresh air which 
was entering the wards was stated to be at the time at a rate 
of over 5,000 cubic feet, per patient per hour, and yet there was 
a distinct feeling of relief and freshness on passing from the 
ward to the open air. This is not surprising if we consider how 
small is the volume of fresh air entering the ward compared 
with the volume of air which would enter by the window. 

Moreover^ the nurses in that hospital were said to prefer 
fireplaces and open windows in the Nurses' Home, to the 
system of ventilation and warming in the hospital. The 
reason of this seems abundantly supplied by the facts just 
mentioned. 

Whilst, however, it would seem to be in the highest degree 
imprudent to trust in any hospital entirely to ventilation by 
propulsion, there are conditions connected with the air of 
large towns, in winter especially, which apparently can only be 
removed by a system of propulsion, combined with purification 
of the air from dust and fog by a system of air washing. These 
conditions are so eminently unfavourable to patients suffering 
from bronchial diseases, phthisis, or other respiratory trouble, 
that it would seem expedient, if not essential, to provide 
at least one or two wards with such a means of purifying the 
air in general hospitals and workhouse infirmaries in large 
towns. 



CHAPTER XIII. 

THE WARD UNIT. 

The Wards. The distribution of buildings on a site depends 
on the form of the buildings. The ward with its necessary- 
adjuncts is the central unit of hospital construction; the form 
of the ward will govern the features of a hospital. 

The first principle upon which the pavilion system is based 
is to limit the number of patients placed under one roof. 

The second is to afford to those patients abundance of 
fresh air by means of cross ventilation. 

The third is to ensure that sunshine shall penetrate as large 
a portion of the building as possible — both inside and outside. 

The number of patients under one roof. 

The ward and its appurtenances under one roof practically 
constitute a small hospital of itself; and the multiplication of 
these, several small hospitals under one administration. 

Dr. Rumsey said, '(i) That the disease in hospitals and 
other large institutions, especially the mortality following 
operations (and universally that after childbirth), are greatly 
increased by the mere aggregation of patients and, ceteris 
paribus, in proportion to the density of that aggregation, 
apart from all other circumstances which might affect success 
or endanger life; (2) that the death-rate calculated, as it 
should be, on the number of patients, and not on the number 
of beds, increases with the size of the establishment and the 
number of its inmates ; and (3) that wherever this assemblage 
of the sick and hurt occurs in the centre of a crowded popula- 
tion, the rate of mortality attains its maximum.' 



The Ward Unit. 



175 



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176 Healthy Hospitals. [ch. 

Whilst this may be accepted as a general truth, no doubt 
the efficiency or otherwise of ventilation and aeration will 
govern the question to some extent. 

The accepted doctrine of late years has been that the 
number of from 100 to 120 patients under one roof should 
not be exceeded. But this is certainly larger than is de- 
sirable in surgical and fever cases. 

The one-story ward units do not contain more than 32 as 
a maximum. And if two floors of wards are superimposed 
the number would not exceed 64 under one roof, even in 
the case of a double pavilion, that is to say, if the staircase 
be so arranged that it will cut off the two pavilions from each 
other, so far as ventilation is concerned. 

The form of ward has to be first considered, under the 
condition whether the ward is to be on one floor or to occupy 
two or more floors. Dr. Mouat says, ' The majority of cases, 
particularly of fevers, lung diseases, &c., demand a purity 
of atmosphere on their own account, which is difficult, if not 
impossible, to obtain in a multiplication of stories.' 

It is very difficult to prevent the air from the lower wards 
from permeating corridors and staircases, and from passing 
up or down through windows so as to affect to some extent 
the air of the wards above or below. 

In the United States, in Germany, and in M. Toilet's 
plans in France, single stories are preferred, for surgical wards 
especially ; and unless under the exceptional condition of 
a town site, two stories are not exceeded for simple medical 
cases. In the Infectious Hospitals of the Metropolitan Asy- 
lums Board and in many country infectious hospitals the 
single-story pavilion is preferred for fever wards. 

Wounded men when agglomerated in a building cause 
a larger amount of contamination to the air than probably 
any other cases, except possibly virulent small-pox, fevers, 
or lying-in women ; for all such cases it is admitted that 
wards without buildings over them, that is to say one-story 



XIII.] The Ward Unit. 177 

buildings, are best, and it may be almost assumed as an 
axiom that wards on one floor would be always preferable 
if circumstances permitted. This accentuates the conclusion 
that, having regard to the condition of town sites, all hospitals 
ought to be situated away from centres of population. But 
this is a practical impossibility for reasons already given. 

On these grounds, in considering the construction of hos- 
pitals, the question must come in as to the nature of the sick 
to be treated. 

Accidents, wounds, virulent infectious disease, lying-in 
women, should always be treated if possible in one-floor 
buildings, which should contain the smallest number of 
patients compatible with economy of nursing. 

There are many cases, such as those suffering from de- 
generative diseases, that do not require either so large a floor 
space or cubic space as acute febrile cases or injuries, and it 
would seem reasonable that hospitals should be so divided 
as to afford a smaller floor and cubic space with superimposed 
wards for the milder and less urgent medical cases ; whilst 
the larger floor and cubic space would be allotted to severe 
surgical and other serious cases. 

The zone of aeration round any hospital should not be less 
than twice the height of the surrounding buildings, so as to 
allow sunshine to fall as fully as possible on the walls and 
surrounding grounds. 

Where more than one superimposed ward has been con- 
sidered unavoidable, in consequence of a confined site, the 
necessity of the arrangement should be discounted by special 
precautions. 

Before considering the form of the ground-plan of a ward 
unit it will be convenient to discuss the section of the ward. 

It is only in one-story buildings that any material difference 
in the shape of the section can prevail. 

A ward which has no building over it possesses many 
facilities for aeration without resorting to artificial appliances. 

N 



178 Healthy Hospitals. [ch. 

But the full advantage of the one-story building for aeration 
will not be secured unless each ward with its ward appurte- 
nances is detached ; for that is the only way in which fresh 
air and sunshine can reach all sides of the building, and 
simplicity form the leading feature. 

We have already shown that for large buildings the removal 
of warm and vitiated air can be advantageously made from 
near the floor level, but in a one-story building the facility 
for renewal of air by ridge ventilation materially alters the 
conditions. 

The most usual section for a simple one-story ward is 
either a flat ceiling covered by a roof sloping to the ridge 
with a ventilating flue, carried from the ceiling to above the 
ridge, or the comparatively flat ceiling may itself form the roof, 
as is the case at the Hamburg Hospital, with ventilating 
flues passing through it. (See Figs. 21, 22, pages 154, 156.) 

Or^ again, the ceiling instead of being flat may slope parallel 
to the roof up to the ridge, where ventilation may be provided. 
This arrangement may be supplemented by dormers and 
windows in the sides and in the gables, if the latter are free. 

If ridge ventilation is resorted to, it is clear that the more 
convenient form is that in which there are fewest angles and 
where the ceiling is made to slope upwards towards the ridge. 

Ridge ventilation is very effective. In the Dresden Public 
Hospital the ventilation in wards of 30 beds was ascertained 
to amount to nearly 5,000 cubic feet per bed per hour, effected 
simply by a roof lantern which occupies rather more than two- 
thirds of the length of the ward, assisted by four aspiration- 
shafts, two in each of the end walls ; the inflowing air being 
supplied by being drawn in over two caloriferes underneath 
the ward. 

M. Toilet's plan for the section <Df the ward, which is adopted 
at Montpelier and at several other French military and civil 
hospitals, is based on the principle of ridge ventilation, and is 
therefore applicable only to one-story buildings. 



xiri.] 



The Ward Unit. 



179 



Ventilator 



M. Toilet adopts the ogival section for the sides of his wards 
(as in Fig. 28, in which the dimensions are given in metres), 
and he bases it on the following considerations : — 

(i) If the air is to find its way to the ridge, the best 
form will be that which dispenses with any angles between the 
walls and the ceiling. 

(2) Of all curved forms the ogival produces the smallest 
thrust in the side wall. 

(3) It creates the smallest friction in the ascending air. 

(4) It offers a smaller surface for absorption of impurities 
than the ordinary form, and is free from all cornices or ledges 
for the deposition of dust. 

(5) This form, whilst being incombustible, at the same 
time dispenses with any compli- 
cated joinery for the roof. The 
construction is extremely simple. 
The inner wall of the ward is 
formed of ribs of double T-iron 
curved to the shape, which pass 
from the floor to the ridge, placed 
about 5 feet from centre to centre, 
where an opening to the air 
along the whole length is re- 
served and provided with valves 
for closing. 

The space between these vertical beams is filled in with 
specially made bricks or tiles ; concrete or any other con- 
venient material might be used, reserving the openings for 
windows, doors, &c. The outer surface is covered with a 
coating of cement; the inner surface finished in plaster, which 
is painted in oil of a suitable colour, and can be scraped and 
renewed when required. 

An outside wall with window spaces is carried up to meet 
a light roof covering. This latter affords an air space of about 
3 feet at the wall cornice between the roof and the ogival 

N a 




Fig. 28. 



i8o Healthy Hospitals. [ch. 

vault, and protects this part from heat or cold ; whilst at its' 
upper end the roof rests on the ogival beams. 

In warm weather and hot climates this construction at the 
ridge favours ventilation, as a maximum of sun heat acts to 
heat the ventilator at that part ; in cold weather this effect 
would not prevail, but the movement of the atmosphere across 
the building would cause an extraction of air. 

M. Toilet claims as an advantage of this form of con- 
struction, that air flowing in through the upper part of the 
window would strike the roof at such a point as to be reflected 
on to the floor space between the beds, whereas in the case of 
a flat ceiling, air similarly entering would be reflected down 
upon a patient's bed. But the fact that the top of the windows 
is necessarily some distance below the apex of the ward is 
a disadvantage when, as in our climate, the penetration of 
sunshine and light to all parts of the ward is an essential 
desideratum. 

The Toilet system has many good points, but it would 
appear to be preferably applicable to warm climates. More- 
over, in a variable and cold climate when there is not much 
sunshine, it is to be feared that the loss of heat through 
the upper part of the ward nearest to the ridge might be 
considerable. 

A good example of a Toilet ward is afforded by the St. Denis 
Hospital unit, in which the rounding of all angles forms a 
main feature. See Figure 29. 

The ward floor should never rest on a solid made-up bed. 
It should always have an air space between it and the ground, 
and this air space should have a dry floor, with circulation of 
air, admission of sunshine, and abundant light. No rubbish or 
dirt should be allowed to accumulate in it. 

Hence the one-story hospital wards should always be well 
raised off the ground. 

In the Montpelier Hospital they are raised to at least 
10 feet above the ground^ by means of a lower floor under the 



XIII.] 



The Ward Unit. 



i«i 



wards, which is used for various business purposes, or left open, 
which has itself an air space underneath. Figs. 30, 31. 




In the Johns Hopkins Hospital the ward floor is about 12 or 
13 feet above the surface. 

In the Dresden Hospital, above mentioned, the wards are 
raised about 7 feet above the ground. On the other hand, 
the Hamburg Hospital is only raised about 3 feet, but 



I«2 



Healthy Hospitals, 



[CH. 




pig 

^ C t^ w|i4 



T3 3 E « 
^ J o g 

,^* rt O nl ij 



XIII.] The Ward Unit. 183 

its warmed floor forms to some extent a compensating 
feature. 

The single-story hospitals of the Metropolitan Asylums 
Board are generally raised 4 feet off the ground, but they are 
not suggested as models, and it may be accepted as an axiom 
that this should be the minimum. When raised 9 or 10 feet 
the basement may be utilized in part at least, as for instance 
at Montpelier, for day rooms. In the Johns Hopkins Hospital 
the part under the wards is used entirely for purposes 
connected with ventilation. But it should never be used for 
stores of a perishable nature, and whatever its height or its 
use it should be light and be kept clean, and its floor should 
exclude damp. 

The area round the wards to a distance of at least 12 feet 
should be covered with impermeable material, and no water 
should be suffered to lodge in the vicinity of the wards. The 
level of the ward floor need not materially affect the distance 
between pavilions, because, whilst it would be preferable for 
the permeation of sunshine to place the buildings at a 
distance of double the whole height measured at least to 
the eaves, yet so far as the ward itself is concerned, it would 
only be absolutely necessary to take into account the height 
of the roof above the lowest ward floor, discounting the 
diminished space by asphalting the whole outer space. In 
this way the space occupied by one-story buildings would not 
necessarily be much greater than that required for buildings 
of two stories or more, for a given number of patients. 

Whilst the ward is the unit of hospital construction, the 
floor space is the unit upon which the form of ward should 
be based. 

It has been shown in a previous chapter that adequate 
space between the beds ought never to be less than from 4 feet 
6 inches or 5 feet — which with a 3-foot bed gives 7 feet 6 inches — 
to 8 feet lineal as the width, and as much more as can be 
afforded. It should be assumed that the bed should stand 



1 84 



Healthy Hospitals. 



[CH. 




'^" cq <o Q 



XIII.] 



The Ward Unit. 



185 



about 12 inches from the wall to allow of circulation of air 
behind ; and there should be from 11 to 12 feet between 
the feet of opposite beds. This would give the minimum 
necessary for administration : and it would bring the length 
of each bed space to about 13 feet or 13 feet 6 inches. The 
ward suggested would thus be 26 to 27 feet wide, with 
a floor space of from 97 feet 6 inches to 108 feet. To this 
any necessary addition must be made in the wall space or the 
length of floor space for the extra aeration wanted in the 
case of wounds, lying-in women, infectious diseases and so 
forth, as well as for facilities for a medical school. 

The following are the dimensions of the wards of some of 
the more recently constructed hospitals in Germany, France, 
the United States, and this country. 



Name of Hospital. 


Height of 
Ward. 


Width of 
Ward. 


Lineal Bed 
Space. 


Floor Space 
per Bed. 


Halle . . . . 


15.9 


29.6 


9.2 


135-6 


Hotel Dieu .... 


*l8 


29-3 


8.4 


125 


Menilmontant 


*I7 


27.9 


7 


107 


Johns Hopkins . 


16 


28.8 


77 


104 


Leeds Infirmary . 


16.6 


27.6 


7-5 


107 


Montpelier .... 


t25 


26.3 


7.2 


108 


Herbert .... 


I3-6 


26 


7-4 


97 


S. George's Union Infirmary 


13 


24 


6 


72 


Moabit, Berlin . 


13-9 


22.6 


6.2 


69 


Hamburg .... 


16.11 


28.8 


5.10 


78 


* First Floor Wards. 


t At c 


entre. 





These conditions being admitted, the form which the ward 
should logically take with the object of allotting to the patient 
the largest space between the beds (that is to say, the largest 
bed space which the proposed floor space will allow of), is the 
rectangular form, because that is the form which allows of a 



1 86 



Healthy Hospitals. 



[CH. 



Corridor- 




U 






J fo IS 20 25 30 JO 40 43 SO ss SO Feet 
Lt^HHHJ ^ 1=1 U=i 1=—! t=j i 



xiii.] The Ward Unit. 187 

maximum of wall space in proportion to the area. It is also 
the form which allows of the smallest distance between 
opposite windows, combined with adequate room for nursing, 
&c. ; and the shorter the distance between opposite windows, 
the more effective will be the cross ventilation. 

The annexed Fig. 3a shows one ward with its appurtenances 
in the new Military Hospital for Colchester. 

The circular form of ward has recently found many advo- 
cates, and it is therefore necessary to weigh the relative 
advantages and disadvantages of the two forms. The circular 
form of ward is more expensive to construct, and it affords 
a minimum of wall space in proportion to the floor space. 
On the other hand, in a circular ward the walls are all avail- 
able for wall space for the beds ; but where the diameter of 
the circular ward exceeds what would be the width of a 
rectangular ward, a larger proportion of the floor space is 
away from the patients in the middle of the ward. For 
instance, in the Antwerp Hospital a ward of 20 beds has 
a diameter of 61 -6 feet. The wall space per bed is about 
9-6 feet, the floor space is 149 feet, the cubic space is 2,525 feet, 
and the distances between the feet of opposite beds would be 
47 feet 6 inches ; and, assuming the beds to be 3 feet wide, 
the actual space between the adjacent beds would be 6 feet 
6 inches at the head, but only 4 feet 6 inches at the foot, and 
of the 149 feet of floor space and 2,525 cubic space, barely 
two-thirds would be within a distance of 14 feet from the 
vicinity of the head of the patient. This proportion of floor 
space at a distance from the patient is comparatively useless 
for its object ; and the consequent additional cubic space 
furnishes a large volume of air, also at a distance from the 
patient and not of much use to him. A measure of this 
waste of cubic space is afforded by considering that in the 
circular ward, whilst the whole floor space per patient is 
149 square feet, that within 14 feet of the wall would only be 
about 90 feet, and the cubic space only little over 1,500 feet 



i88 



Healthy Hospitals. 



[CH. 



out of the total 2,525 feet. Moreover, in large wards the 
distance between opposite windows in the circular ward is 
far greater than is desirable to ensure the aeration of a ward 
by means of windows. The sweeping out of all the impure 
air from the ward occasionally, so as to start afresh with pure 
air, is best effected by the direct action of currents of fresh air 
brought in by open windows placed on opposite sides of the 
wards. The distance between windows for this purpose must 

not be too great to 

Hoepital 
Ground Floor 



Burn/e 
Plan of ward unib 



7 



Award Linen 
B Foul Linen Shoot 



prevent their efficient 
action in moving 
the air. Experience 
shows that a width of 
24 feet affords very 
satisfactory results, 
and that opposite 
windows for such an 
object should in no 
case be more than 
from 30 to "^^ feet 
apart. The space 
between the windows 
should not be ob- 
structed by walls or 
partitions. 

The same object 
renders it necessary 
to limit the number 
of patients — that is 
to say, the sources of 
impure emanations 
— placed between opposite windows to two. 

In the Antwerp circular ward the central space is occupied 
by a concentric circular structure used for a nurses' room, 
built round the shaft for ventilation, which impedes the cross 




Fig- 33. 



XIII.] 



The Ward Unit. 



189 



— Burnley Ho epical 



ventilation from windows ; and in the Burnley Hospital in 
one ward the cross ventilation is impeded by a central stair- 
case leading to a sun room on the roof. 

In a rectangular ward of 38 feet wide, affording similar 
floor space to the Antwerp circular ward, the wall space per 
bed would be about 10 feet 8 inches^ and the distance between 
opposite beds would be about 14 feet ; assuming the beds to 
be 3 feet wide, the distance between the beds at both ends 
would be 7-8 feet, which is ample for nursing purposes ; the 
whole floor and cubic 
space would be situ- 
ated within 14 feet of 
the patient's head. 

So far as the con- 
venience of a medical 
school is concerned, it 
is said that the large 
proportion of floor 
space in the middle of 
the ward, in the case 
of a circular ward, 
and away from the 
beds is convenient, in 
that the bed of the 
patient under obser- 
vation can be wheeled 




Fig- 33 «• 



out into that space, and thus ample means be afforded for the 
students to see and hear all the remarks of the Clinical Professor, 

Figs. Q,-^, 0,'^ a and '>^'>, b show a ward of the Burnley Hospital 
built by Mr. Waddington, in plan and section, with the day 
or as it is termed sun room over the ward, into which patients 
can be taken by means of a bed-lift. 

The circular form of ward is very cheerful, because the 
windows catch the sunshine at a larger number of angles than 
is the case with the rectangular form. 



IQO 



Healthy Hospitals. 



[CH. 




XIII.] The Ward Unit. 191 

The circular form is also convenient for artificial ventilation, 
in that the air can be extracted at a central flue and admitted 
equally all round the circumference. The larger area over 
which the admission of air is spread favours its coming in 
gradually, whilst a higher velocity may be given to the central 
outflow. 

The advantage of the circular ward lies in the absence of 
angles. This advantage can be obtained to some extent in 
the rectangular ward by rounding all angles and avoiding all 
cornices, as shown in M. Toilet's St. Denis Ward, Fig. 29, 
and by placing a window at the corner of the ward, between 
the end beds and the wall. 

The height of the ward for purposes of daylight must depend 
upon the width. Its height is also dependent to some extent 
upon its length, because the breadth, the height, and the length 
all influence the efficient circulation of air ; it is of course 
assumed that the windows are carried up high both to admit 
daylight and prevent stagnation of air in the upper part of the 
ward. For a small single or double ward a height of 1 2 feet might 
suffice, but in wide wards due proportion for the circulation of 
air requires that this height be increased, and the table given 
in a former page shows that hospital architects have recognised 
this necessity. On the other hand, any height beyond that 
actually required means unnecessary cost in construction and 
more space to be warmed. 

The floor space, the lineal wall space per bed, and the width 
of ward being decided on, the number of beds in the ward 
regulates the length, or in circular wards the diameter. 

Whilst the medical man prescribes for the sick, he depends 
for the execution of his orders upon the nurse. The nurse 
applies the remedies, gives food, and regulates the atmo- 
sphere, as an hourly continuous duty. 

The disciplinary and economical dispositions in a hospital 
require that each nurse should have the patients allotted to 
her placed in one ward, under her immediate eye; and the 



192 Healthy Hospitals. [ch. 

head-nurse should be supreme in the ward which she nurses. 
Moreover, as economy of labour in administering the hospital 
is a main object to be sought in hospital construction, the 
hospital should be so laid out as to enable the largest possible 
number of patients to be nursed by a given number of nurses. 

The number of patients to be placed in a ward will there- 
fore depend upon the number which can be efficiently nursed, 
and the form of the ward must be calculated to facilitate 
nursing as well as to ensure free circulation and change of air. 

Miss Nightingale says that ' a head-nurse or sister can 
efficiently supervise, a night nurse can carefully watch, 32 beds 
in one ward ; whereas with 32 beds in four wards this is 
impossible,' (Report on Cubic Space in Workhouses.) 

Miss Nightingale further shows (in her ' Notes on Hospitals,' 
1 863) that if the annual cost of nursing be capitalized, and if 
a hospital for a given number of sick be divided into wards of 
nine patients each, the cost of nursing in perpetuity would be 
£\i'^ per bed : whereas, if the hospital were divided into 
wards of 25 beds each, the cost would be ;^ 231 per bed, and 
with wards of 32 beds, the cost would be ;^22o per bed. 

It has followed from these considerations, that from 20 to 
32 beds have been taken as the unit for ward construction 
to include the number under one sister or head-nurse. In 
hospitals where cases of more than ordinary severity are 
likely to be received, it would be necessary to diminish the 
size of the wards on grounds of health, and thus to make 
some sacrifice of economy of nursing for the sake of the 
patients. 

The apportionment of beds between Medical, Surgical, and 
other cases depends on local conditions. In the Metropolitan 
Asylums Board Hospitals, excluding small-pox, the per- 
centage of diseases provided for is about 72 for scarlet fever, 
10 for diphtheria, and 9 each for enteric and other diseases. 

The following table shows the number of beds provided in 
large and in small wards in various hospitals : — 



XIII.] 



The Ward Unit. 



19: 



Name of Hospital. 


Accom- 
modation. 


General Wards. 


Small or Separation 
Wards. 


Percentage of 
beds in Wards 
ofoneand two 
beds each to 
total accom- 
modation. 


No. of 
Wards. 


No. of 
Patients 
in each. 


No. of 
Wards. 


No. of 

Patients 
in each. 


Hamburg .... 


1340' 


30 
II 


30 J 
14) 


II 

II 

119 


■! 


10.5 


S. Marylebone In- 
firmary. 


744 


24 


28 


36 


2 


9.6 


Tenon (Menilmon- 
tant) 


726 


20 
2 

8 


22) 


12 
16 
10 

42 


4) 
^\ 

2 r 
I ) 


8.5 


Herbert Hospital . . 


650 


IS 
5 
I 


20) 


8 


I 


1-2 


S. Eloi (Montpelier) 


600 


12 
6 
6 

4 


28 i 

lof 

8; 


44 


W 


19-6 


S. Thomas' .... 


573 


15 

3 
7 


28) 

20 > 
8) 


17 
3 


W 


6.4 


Berlin Military Hos- 
pital. 


504 


14 


16 


27 
24 
23 


H 


9.1 


Antwerp 


380 


16 


20 


60 


I 


157 


Johns Hopkins . . 


361* 


10 


24 


I 

27 
64 


■! 


32.6 


Leeds Infirmary . . 


328 


4 
6 


32 ) 
28 \ 


2 

5 


:i 




Norfolk and Norwich 


218 


6 
2 


24 \ 
17 ) 


I 

17 
3 


ii 


16.9 


S.Denis 


166 


7 
4 


11 


6 
10 


;l 


13.2 


^ Includes accon 
and violent 
^ Includes about 


imodatic 
latients. 
28 payir 


n for 72 paying p 
ig patients, chiefl 


atients a 
y in one- 


nd 29 de 
Ded ware 


lirious 
is. 



194 Healthy Hospitals. [ch. 

The actual ward figure for each hospital must depend on 
the nature and to some extent on the size of the hospital. 

But to every large ward there should be attached small 
wards. These form part of the ward unit under the charge of 
the ward sister. 

Patients suffering from injuries to, or disturbances of, the 
nervous system suffer much from light, heat, noise, or presence 
of other patients in a ward. Other cases require isolation 
for treatment or for observation. 

The number of these small wards, and the question as to 
whether they are to accommodate one or two or more 
patients, is necessarily a matter which the medical advisers 
on the local wants of the hospital must define in the original 
plan. It somewhat depends upon the provision made for 
paying patients. 

But there seems to be a growing feeling that the number of 
small wards is insufficient in most modern hospitals. Thus 
the provision of one and two-bed wards in St. Thomas's 
Hospital amounted to 6-4 per cent, of the total ; but in the 
Hamburg Hospital there has been provided 10-5 per cent, of 
one-bed and two-bed wards ; in the Antwerp Hospital about 
15-7 per cent. ; in the Montpelier Hospital nearly 20 per cent. ; 
and in the Johns Hopkins Hospital nearly '>,'>, per cent. 

From the conditions under which these smaller wards would 
be occupied the floor space and cubic space per bed should 
at least be full; and it would appear that the floor space 
allotted to separate wards rarely falls below 120 square feet, 
and occasionally amounts to 160 square feet per bed, with 
cubic space varying from 1,450 to 2,000 feet. A one or a two- 
bed ward may be warmed and ventilated by means of a 
ventilating open fireplace and the window, if the upper part 
of the window is arranged to fall in and make a hopper 
ventilator ; but with more beds, a shaft to remove foul air and 
additional inlets for fresh air would probably be required, as 
well as additional heating arrangements. These should be 



XIII.] The Ward Unit. 195 

adapted to such specialities of treatment as might be necessary, 
and their position with respect to the main ward, nurses' rooms 
and ward appurtenances, should be such as to facilitate con- 
venience of nursing. 

Day Rooms and Sun Rooms. 

It has become the practice in some of the more recent 
hospitals to make a day room an integral part of the prin- 
cipal ward. This is the case in the Royal Infirmary, Liver- 
pool. It is shown in the sketch of the Hamburg Hospital 
ward. It is adopted in another form in the Johns Hopkins 
Hospital. In the Montpelier Hospital day and dining rooms 
are provided in the basement floor under the wards. The 
Bourges Hospital, also on Mons. Toilet's plan, provides a small 
day room to each ward. 

Some of the new circular hospitals in this country provide as 
one of their principal features a sun room, placed on the top 
of the circular ward, protected by glazed sides and warmed by 
steam-pipes, with a circular open promenade round it. The 
access to this is sometimes made through a staircase central 
to the ward. This obstructs ventilation, is necessarily dark, and 
furnishes dark corners, in which, sometimes patients' clothes 
and sometimes rubbish, is accumulated, and it does not allow of 
patients in their beds being brought into the sun rooms. A 
more recent arrangement is shown in Fig. 33, 2)?)^^ 33^- This 
leaves the circular ward free from impediment, except from 
a column in the centre which forms the chimneys and ex- 
traction flues, and access is afforded to the sun room by 
a staircase outside the ward, adjoining which is a lift for beds, 
so that a patient can be rolled out of his ward and conveyed 
up by the lift into the sun room. 

The sun room when properly utilized forms a very useful 
and pleasant addition to a ward. 

In some cases these rooms are divided into a reading room 
and a smoking room. 

O 2 



196 



Healthy Hospitals. 



In the Breslau Surgical Clinical Hospital, in addition to 
a day room placed at the end of the ward, the object of 
a sun room is to some extent obtained by an open air 
verandah along the south side of the ward, into which 
patients' beds can be moved. 



Breslau Surgi cal KfJnik - 




— Scal e — 
S ^ 7 8 9 10 II 12 13 M- IS le n i§_f^_zo Metres 



a. Day Room. 

b. W.C, &c. 

c. Isolation Ward. 

d. Bath Room. 
e. Linen Store. 

f. Ward for recent operations. 



g. Operating Theatre. 
h. Undressing Room. 
i. Instruments. 
o. Open Verandah. 
/. Attendant. 
r. Laboratory. 



Fig- 34- 



It is not assumed that many of the patients would be able 
to leave their beds to occupy the day room. 

The area of day rooms in the Berlin Friederichshain Hos- 
pital would appear to be nearly 33 feet per bed in the ward it 
accommodates. 

The Johns Hopkins Hospital would afford nearly 13 super- 
ficial feet to each of the patients occupying the large ward. 
In the Hamburg Hospital it is a little over 15 superficial 
feet per bed in the wards. In the Bourges Hospital the day 
room only affords 5 superficial feet per bed. In the Tenon 
Hospital, Menilmontant, the floor-space for the day room is 
nearly 10 superficial feet per bed. 



CHAPTER XIV. 

THE WARD UNIT {continued). 

Ventilating Inlets and Outlets^ Windows^ Doors, 
Walls, Floors. 

Ventilating Inlets and Outlets for Air. — No inlet or outlet 
ought to be placed in the floor. Hot-water pipes ought never 
to be placed in channels in the floor with open gratings ; such 
a position only affords receptacles for dirt ; when placed in the 
middle of the ward, patients spit down them. 

In the Johns Hopkins Hospital some of the extraction out- 
lets are placed under the beds, but this does not entirely 
remove the objection to their becoming receptacles for dirt. 

Any such opening should be above the floor-level, and 
therefore they are best in the side walls, with a sloping back, 
so that anything thrown into them falls back into the ward. 
Whilst outlets for extraction shafts may preferably be placed 
near the floor-level, inlets for the warmed fresh air should not 
throw cool air, or air whose rapidity of movement makes 
it feel cool, on to the feet. They are therefore best placed 
somewhere above 5 feet or 6 feet from the floor-level. 

The velocity of inflowing air should never exceed 2 feet per 
second. Air should preferably flow in at a velocity of i foot or 
I foot 6 inches per second. The velocity of outflow in outlet 
flues as they leave the openings into the wards should, simi- 
larly, not exceed 1 feet per second on entering the mouth of 
the outlet, which should be large enough to limit the velocity 
to that speed; but it may travel along the outlet flues at 
a rate of from 3 to 4 feet per second or more. 



198 Healthy Hospitals. [ch. 

Windows. — Second only to air, is light and sunshine 
essential for growth and health ; and it is one of Nature's 
most powerful assistants in enabling the body to throw off 
those conditions which we call disease. Not only daylight, 
but sunlight ; indeed, fresh air must be sun-warmed, sun- 
penetrated air. The sunshine of a December day has been 
recently shown to kill the spores of the anthrax bacillus. 

In her article on 'Nursing' in Quain's Dictionary, Miss 
Nightingale observes that ' light should be meant to include 
colour, pleasant and pretty sights for the patient's eyes to rest 
on — variety of objects, flowers, pictures. People say the effect 
is on the mind. So it is ; but the enlightened physician tells 
us it is on the body too. The sun is a sculptor as well as 
a painter. The Greeks were right as to their Apollo.' 

The form of the windows must be considered first, in their 
aspect of affording light as a necessary means of promoting 
health ; secondly, of affording ventilation ; thirdly, of facili- 
tating nursing and of enabling the patients to read in bed. 

Light can always be modified for individual patients. 

In order to give cheerfulness to the wards, and to renew 
the air easily, the windows should extend from within % feet 
or 2 feet 6 inches from the floor, so that the patients can see 
out, to within 1 foot, or if possible 6 inches, from the ceiling. 
Given a certain area of window, this would preferably be 
distributed in a tall and narrow window than in a wide and 
short window. 

No room can be cheerful in which there is much space 
between the top of the windows and the ceiling, or between 
the bottom of the windows and the floor ; or in which a portion 
of sky is not seen from every part of the room. The vertical 
arc of sky thus visible should not be less, in the aggregate, 
than 5° in any part of the room. 

In special cases the lower part of the window could be 
shaded, but if a window is constructed too high from the 
ground, it causes a permanent want of cheerfulness. 



XIV.] The Ward Unit. 199 

In the pavilion plan of construction the windows are, as has 
been already explained, placed on each side of the ward, with 
not more than two beds between adjacent windows, so that 
plenty of light may be thrown on each bed, for facility of 
nursing. 

Where the corridor system prevails and the windows are on 
one side only, the dimensions of the windows should be at least 
one-third more^ in proportion to the contents of the ward, 
than in the pavilion system with opposite windows. 

To promote cheerfulness, and for ensuring cleanliness in the 
angles of a rectangular ward, it is desirable to place a window 
at the angle next the wall. These windows need not be of 
the same width as those which regulate the bed spaces. 

The distance between the windows must be regulated by 
the lineal bed space. Window openings themselves may 
generally be assumed at 4 feet 6 inches wide, with one window 
to two beds, or narrower with one window to each bed. The 
sides of the window openings may be splayed about 6 inches 
on each side into the ward. 

In wards of military hospitals, affording about 1,250 cubic 
feet per bed, and with one window to two beds, the bed space 
between the end wall and the first window was made 4 feet 
6 inches, and the spaces between the adjacent windows 9 feet. 
This afforded a lineal bed space of 6 feet 9 inches. But with 
a larger lineal bed space, the distance between the windows 
and the width of windows might be somewhat increased. An 
end window to a long ward is a great element of cheerfulness, 
and materially assists in the renewal of the air. It is essential 
to cleanliness that every part of the ward should be light. 
But the actual amount of window space must depend much 
on situation ; in a town the amount sufficient for a free 
country aspect would be gloomy. 

The window space will appear cheerful with light-coloured 
walls, whereas it may appear gloomy if the walls are dark- 
coloured. 



200 



Healthy Hospitals, 



[CH. 



The area of window space for light must therefore vary 
with climate, and also with position of a hospital, whether in 
a town or otherwise. 

The architect Lorenz of Berlin appears to lay down 32 
superficial feet of window space to each bed if the windows are 
on one side, as is the case with wards on the corridor system, 
and 1 6 superficial feet per bed with wards on the pavilion 
system. But this rule would omit considerations of cubic space. 

In this country the area of window space with respect to 
floor space has been generally looked upon as the index to 
refer to ; but the cheerfulness of a room will mainly depend 
upon the area in proportion to the cubic contents. One 
superficial foot of window space to from 50 to 70 cubic feet of 
space, according to position and climate, will afford a light 
and cheerful room. Where there is a verandah more window 
surface would be necessary in this climate. 

The following table shows the proportion which has been 
adopted in different hospitals, calculated on this basis. It 
will be observed that there is no general concurrence in 
window space judged by this rule. 

Glazed Surface. 



In Towns. 



S. George's Union Infirmary 

Leeds Hospital 

Hotel Dieu* 

Tenon (Menilmontant) * . . 

Halle 

Herbert 

Moabit 

Johns Hopkins 

Montpelier . . " . . . . 
Hamburg 



One Square Foot of Window 
Space 

to Square Feet to Cubic Feet 
of Floor Space, of Cubic Space. 



4.6 
4.9 

6.7 

6. 
8.2 

5-1 

6.2 
4.8 
47 
5-3 



60 
80 

175 

102 

123 

69 

1^ 

7^ 

112 



* First Floor. 



XIV.] The Ward Unit, 201 

The loss of light through the windows varies with the 
quality of glass. 



Polished British plate glass, 4 in. thick, 


intercepts 


,13 per 


cent 


of the light. 


36 oz. sheet glass .... 


■)■) 


22 


» 


» 


Cast plate glass, 4 in. thick 


■>■) 


30 


j> 


j> 


Rolled plate glass, 4 corrugations in 










an inch 


j> 


53 


» 


)> 



Clear glass is thus of great importance, and the thicker 
it is, consistent with clearness, the better, because thin glass 
allows of a more rapid loss of heat, and it is essential, 
especially in this climate, to economize heat in wards, with so 
much outer wall as the provision of windows on both sides 
requires. 

The loss of heat through windows amounts to that lost by 
radiation added to the loss of heat by contact with air. 

It may be assumed with thin glass that the temperature of 
the outer surface of the glass is a mean between the tempera- 
ture inside the room and that of the outer air. 

With thick glass the conducting power of the material may 
be taken into account, as in the case of a wall. 

From these considerations it is desirable to make the 
windows of thick plate glass. Double windows of ordinary 
glass would very largely reduce the loss of heat and facilitate 
ventilation ; but they would greatly diminish the light passing 
through. 

The loss of heat with double windows is much less than 
that with single windows, and they have the advantage not 
only of transmitting less heat, but, from the temperature of 
the inside glass being greater, less radiant heat is absorbed 
from the occupants of the room. Peclet found that the loss 
of heat in double windows increased somewhat with the 
distance apart of the inner and outer glass, owing probably to 
the greater facility for currents of air in the wider space 
between the glass. 



202 Healthy Hospitals. [ch. 

Thus, with an intermediate space between the windows of 
•8 of an inch, the loss of heat of the single window to that of 
the double window was in the proportion of i : -47 ; with 
a distance apart of i inches, the proportion was as i : -55 ; 
with a distance apart of 2-8 inches, which is nearly what 
exists in practice, with double windows the proportion would 
probably be as i : -6. 

On these grounds the windows of all hospitals should be 
double. This may be effected either by double sashes or by 
a French sash inside and a double-hung sash outside ; but 
according to Peclet a better result for saving heat may be 
effected by double glazing the lower sashes. In this case the 
window bars must be prepared on their inner side to receive the 
inner plate of glass ; this should be laid on a narrow flannel 
band and secured by means of a wood fillet screwed into the 
side of the window bar. 

The flannel will be the most effectual way of keeping the 
inner surfaces clean. Dirt penetrates to the space between 
the two sheets of glass, by means of the constant inflow and 
outflow of air going on as the result of changes of tempera- 
ture, and the flannel acts as a filter to retain the dirt which 
the outer air would otherwise carry into and deposit in the 
interspace. 

The method of fixing the fillet should be one that will 
afford easy means of removal for cleansing. The double 
glazing has however the disadvantage of always obstructing 
light, whereas, in the case of the window with a double sash, 
one sash can be left open at times, or altogether removed in 
summer. 

The best form of sash for ventilation in this climate is the 
ordinary sash, opening at top and bottom ; but windows made 
in three or four sections, each of which falls inwards from an 
axis at the bottom of the section, have been extensively used 
in hospitals, and possess many advantages ; although it is 
certain that the air of the wards cannot be so thoroughly 



XIV.] The Ward Unit. 203 

changed by means of these windows as by means of the 
ordinary sash. 

It would therefore appear desirable to make hospital 
windows in either two or three divisions, the lower divisions 
occupying between § or | of the height of the window, the 
upper portion between | or | ; the upper portion being hung 
on hinges at its lower part, so as to fall inwards. Glazed 
triangular sides project into the room into which it falls, so 
as to create a sort of hopper when open, which admits fresh 
air upwards and prevents side draughts on the patient. The 
lower half of the window may be preferably a double-hung 
sash, which with the aid of a deep bottom bar enables an 
opening to be maintained at the centre bar, without any 
opening at the bottom bar which might create draught upon 
the patient. 

If desired, a French casement window may be adopted ; 
this latter affords the fullest area of opening. 

Although double windows would greatly economize heat, 
yet there would be complications in making the upper in- 
falling flap double. 

A combined double and single window will enable the 
most essential part of the window, viz. the lower part, to 
be made double, and would prevent radiation from the 
patients. 

Figure '>,^, p. 304 shows a window in the Surgical Ward 
of the Gottingen Hospital, of which the lower half {a, a) 
is double, opening inwards as double casement windows ; the 
middle part {b, b) is a casement opened by cords, above and 
independent of the former ; and the upper part {c) falls in 
to create a hopper ventilator. In the Surgical Hospital, 
Bonn, the upper single portion of the window is made to 
open by falling inwards, and the lower casement, occupying 
two-thirds of the height of the window, is made double. 

The woodwork of windows, as well as all woodwork in a 
ward, should be of hard wood painted and varnished, so as 



204 



Healthy Hospitals. 



[CfT. 



to admit of easy washing and cleansing. The cleanest and 
most durable material is varnished light-coloured wainscot 
oak or teak. 




C/inical Surgical Hospital 
Gotting&n 



a. Double Window casement. 

b. Single Window casement. 



c. Single Window falling in on bottom hinge. 
d. Interspace between Windows. 

Fig- 35- 



Doors. — Ward doors should be arranged in number and 
position so as to facilitate nursing and prevent panic in 
case of fire. They must be large enough to allow of the 
passage through of sick on moveable stretchers. 

Double doors are not very convenient, because the opening 



XIV.] The Ward Unit. 205 

of the whole door is somewhat troublesome, unless they are 
made on Mr. Appold's plan, in which the leaves are con- 
nected by a lever at the top and the two leaves open 
simultaneously in opposite directions. 

In large wards, operation-rooms, &c., double doors are 
often necessary, and should afford an opening of about 5 feet. 

Single doors should afford an opening of from 3 feet 
8 inches to 4 feet ; which would allow of the passage of 
stretchers, trays on wheels, &c. It is generally convenient 
that the principal ward-doors should open both ways, and be 
self-closing. 

To prevent panic in case of fire, a second door opening 
outwards should be placed at the end of the ward opposite 
the principal entrance. 

Doors into bath-rooms should be large enough to allow 
of the passage of a moveable bath ; probably 3 feet 9 inches 
would suffice. The doors for lavatories should be of the same 
width, but doors for w.c.'s might well not exceed 3 feet 
4 inches. 

The material for ward-doors is preferably hard wood, such 
as oak, varnished, which can be easily washed. 

The construction of all doors in and near wards should 
be such as to present as few projections, interstices, or other 
places for the accumulation of dust as possible. The upper 
part of the entrance doors to wards and all swing doors might 
advantageously be glazed. 

Walls. — All walls should be protected from damp rising 
in them by a dampcourse of slate, asphalte, an efficient form 
of glazed brick, or some impervious composition. The top 
of the wall should similarly be protected so that rain shall 
not sink in at the top ; and eaves or cornices should project 
sufficiently and be so formed as to prevent a drip from the 
roof on the face of the wall. The walls should be such as 
will allow of a smooth surface. A wooden hospital has the 
advantage of being erected rapidly; but the numerous joints 



2o6 Healthy Hospitals. [ch. 

and chinks, which are favourable to the permeation of air, 
become after long use adverse to cleanliness. A wall of 
brick or of some material which can be used without pre- 
senting chinks on the surface, is therefore preferable in 
hospitals of any degree of permanence 

With a view to economize heat in winter, and to keep 
the rooms cool in summer, the walls should be hollow, care 
being taken that the hollow air-space is closed in top and 
bottom to prevent circulation of the enclosed air. 

All hospital wards should be ceiled, and the roof con- 
structed of a good non-conducting material. If of slates or 
tiles, they should invariably be laid on boards and felt. 

Our gradually extending knowledge into the causes of 
disease shows that in houses and hospitals where diseases 
have appeared to linger, or to break out afresh after long 
periods of being shut up, there has generally been ample 
opportunity for dirt to lodge in the cracks of the floor 
or the interstices of the walls, or for nitrogenous organic 
matter to be absorbed into plaster, where warmth and 
moisture may favour its decomposition. And there has 
been no more striking exemplification of the value of clean- 
liness than that afforded by Sir Joseph Lister's system of 
treating wounds; a system based on the most absolute 
cleanliness. 

It has followed that this absolute cleanliness is a necessary 
feature of a well-managed hospital. Now this means that 
the walls shall afford no lodgement for dust, that there shall 
be no cracks in woodwork, or between the woodwork of 
windows and doors and the walls, and that walls and floors 
shall not be absorbent nor afford corners where dirt can lodge 
or interstices into which dirt can penetrate. As regards 
corners, it is possible to scrape with a penknife from the floor 
in the corner of an ordinary room an amount of dirt which is 
surprising. In a hospital this dust may consist of epithelium, 
threads of lint, and other objectionable matter. This may be 



XIV.] The Ward Unit. 207 

avoided by replacing the angles made by the walls with each 
other and with the ceilings and floors with curves or quadrants, 
the concave surfaces of which face the wards ; in fact, by 
carrying out to their fullest extent the principles advocated 
by M. Toilet. 

As regards interstices or cracks, the best lining for a 
hospital ward would be an innpervious polished surface, which, 
on being washed with soap and water and dried, would be 
made quite clean. Plaster, wood, paint, and varnish all 
absorb the organic impurities given off by the body, and 
any plastered or papered room, after long occupation, ac- 
quires a peculiar smell. Ammonia is always found on surfaces 
of occupied rooms. In a discussion in the French Academy 
of Medicine, a case was mentioned in which an analysis 
had been made of the plaster of a hospital wall, and 46 per 
cent, of organic matter was found in the plaster. No doubt 
the expensive process which is sometimes termed enamelling 
the walls, which consists of painting and varnishing with 
repeated coats, somewhat in the manner adopted for painting 
the panels of carriages, would probably prove impervious for 
some time, but it would be expensive, and very liable to be 
scratched and damaged. 

Parian cement polished has been much used for wall 
surfaces, but it is costly, and it is difficult to get it of an 
even colour, it becomes discoloured apparently from internal 
change, and is therefore disappointing ; it can only be applied 
on brick or stone walls, and not on woodwork or partitions, 
because, being very inelastic, it is liable to crack. The want 
of elasticity in Parian cement is unfavourable to its use in 
ceilings. Cracks in a hospital ward are inadmissible, as they 
get filled with impurities and harbour insects. For this reason 
it is advisable that all division walls in hospitals in connexion 
with the sick be built of brick. 

Glazed bricks have however been largely adopted as a lining 
for wards of late years; but from their numerous joints these 



2o8 Healthy Hospitals. [ch. 

can only be safely used provided the joints are most carefully 
made in cement and painted. A very good specimen of 
glazed brick is to be found in the Burnley Hospital, where the 
bricks were specially ordered to be made as true and straight 
in the edge as possible : they were laid in very fine mortar: 
the joints were scraped out and pointed with Keene's cement, 
and this was painted with two coats of white enamel — 
albarine, or Aspinall's enamel — a mixture of zinc white and 
varnish. As these joints after five years show no sign of 
imperfection, it may be assumed that with care the glazed 
brick will afford a safe wall-surface for wards. 

In default of a satisfactory impervious wall covering, cem"^ent 
well trowelled to a flat surface and oil-painted makes a good 
wall, which can be washed with soap and water, and scraped 
and repainted from time to time. A safe arrangement is 
plaster lime-whited or painted, provided it be periodically 
scraped so as to remove the tainted surface, and be then 
again lime-whited or painted. 

When plaster is used, it is essential, for the reasons before 
mentioned, that at the expiration of a very few years the 
whole outer coat of plaster should be removed from the 
walls and ceilings, and new plaster substituted. Of course 
these arrangements require the wards to be periodically 
vacated, which is of itself a great recommendation to the 
use of plaster. 

The material used for colouring walls connected with the 
sick should be one capable of being washed. It should present 
a cheerful light colour, but of a tint restful to the eyes. 

The walls and ceilings should be quite plain, and free from 
all projections, angles, cornices or ornaments which could 
catch or accumulate dust. As already mentioned, angles at 
the junction of walls and ceilings and elsewhere should be 
rounded, or rather coved. 

Floors. — It is essential that wards for the sick should be 
raised above the ground level, with a free air-space under. 



XIV.] The Ward Unit. 209 

This view is endorsed in the most recent hygienically built 
hospitals, as for instance the Johns Hopkins, the Montpelier 
Hospital, and the Hamburg Hospital. 

Broadly speaking, the higher the floor is above the ground- 
level the better. In the first place, aqueous vapour is always 
rising more or less from the ground. A layer of cement or 
of concrete will not entirely prevent the ground air from rising 
from the part under the building : an interposed layer of 
asphalte may do so ; but it is" liable to cracks, in which case it 
would not prevent the ground air from rising. Moreover, the 
ground air will in any case rise from the space round the 
building ; and for that reason it is essential to cover the 
spaces between pavilions with asphalte or tar pavement. 

In this country this argument has not been fully recognized, 
although it is even more important in consequence of the 
dampness of the climate and soil. Indeed, some of the 
medical men in the hospitals of the Metropolitan Asylums 
Board have stated that those wards which have tar-paved 
surfaces between the pavilions are more favourable to the 
recovery of patients than those where the surface is garden or 
grass. 

When the ward is raised above the ground-level, the spaces 
thus left under the wards should be light, accessible, and kept 
clean and free from any substance which could create un- 
healthy emanations ; for instance, they should not be used as 
coal-stores, or stores for perishable things. 

As regards the material for the floor of a ward, if any one 
will examine the floor of any hospital when there are only 
small spaces at the joints between the floor boards, he will 
find these joints filled with filthy matter. If the floors are 
washed, this is carried down into the cinders and other sub- 
stances used for deadening sound. If the boards are taken 
up, it will be found that this dirt has penetrated and lodged 
beneath the floor, and that it affords a birthplace for putre- 
faction; and possibly for germs of diseases. As bearing on 

P 



2IO Healthy Hospitals. [ch. 

this, Dr. Emmerich of Leipzic investigated the effect on the 
air of the room of the material used for deadening sound 
between floors. He found the substances under the floors of 
dwelling-rooms highly contaminated with nitrogenous organic 
matters, and their decomposed products. 

Professor Carnally and Miss Johnston in 1889 made cor- 
roborating experiments on the material of floors at Dundee, 
and concluded that the deafening material for floors is 
a source of contamination of the air of dwellings, in that it 
furnishes a good and suitable medium for the growth of 
micro-organisms and gives off" fetid gases from putrefaction, 
provided the necessary factors — moisture, warmth, and nitro- 
genous organic matter — are present. 

On these grounds there should be no sawdust, cinders, or 
other organic matter subject to decay under the floor. When 
one ward is placed over another it is essential that the floor 
should be non-conducting of sound. But the above-men- 
tioned experiments show the great care that must be taken 
to watch the character of the material used for this purpose. 
The floors should also be so formed as to prevent emanations 
from patients in the lower ward from passing into the upper 
wards. 

Similarly, where there are skirting-boards round the ward, 
some interstices will be found to exist, affording a receptacle 
for dirt. 

It is partly because this foul matter may be carried down 
under the floor by water, and also because of the damp intro- 
duced into the ward, that medical men generally forbid the 
practice of washing the floors. 

Many matters are spilt on a hospital floor which should 
not be allowed to sink in, therefore the surface of the floor 
should be as non-absorbent as possible. Floors of stone, 
cement, or asphalte, although favourable for cleaning, are too 
cold for sick persons, and would be equally bad for nurses 
who have to occupy the wards by day and by night ; hence 



XIV.] The Ward Unit. 21 1 

for the sake of warmth to the feet, floors must in this country- 
be either of some material like marble terrazzo warmed under- 
neath as in the case of the Hamburg Hospital, or else of wood. 
All wooden floor-boards must be of well-seasoned wood 
carefully planed, grooved, and tongued. If of deal or pine 
they require especial care. With the best workmanship and 
materials, interstices between the boards will appear, and their 
width will vary with changing meteorological conditions ; debris 
of all sorts will be gradually sifted through and accumulate 
putrefying organic filth between the floor and ceiling. 

One plan for delaying this result is to caulk the interstices 
between the floor-boards, like a ship's deck, to about half 
their depth, then to fill up the other half to floor-level 
with marine glue; thus connecting the boards by means of 
an elastic waterproof surface. This floor should be saturated 
with drying linseed oil, well rubbed in, stained not too dark 
so as not to hide dirt, beeswaxed with turpentine, and polished. 
If the floor-boards are alternately wetted and dried in the 
process of washing, their consequent expansion and contraction 
may form openings between them and the marine glue. In an 
old hospital, cracks can be filled in with clean sand, and the 
upper part of the joint made good by putty and then painted. 
Oak, teak, or any other close hard wood, with close joints, 
with iron tongues, oiled and beeswaxed, rubbed to a polish, 
makes a very good floor, and absorbs very little moisture. A 
floor of teak or oak with joints as close as the best parqueterie, 
affording no inlet for the lodgement of dirt, and the floor 
saturated and the interstices filled with paraffin or even bees- 
wax, makes a very good floor. 

An economical floor can be obtained by first laying rough 
deal boards and covering them across with thin, narrow, 
closely-laid oak boards beeswaxed and polished. The double 
boards assist in preventing the penetration of dirt. 

A very good hospital floor is one in use in Germany, which 
is of pine wood, oiled, lacquered, and polished, so as to 

P 3 



212 Healthy Hospitals. 

resemble French polish. It is damp-rubbed and dry-rubbed 
every morning, which removes the dust. The only objection 
to it is want of durability. 

The processes above mentioned render the floor non- 
absorbent, and do away with the necessity of scouring. A 
French floor, oiled, beeswaxed, and polished, stands the most 
wear and tear, but it must be cleaned by a frotteur, which is 
more laborious than scrubbing, and does not remove the dust. 
The proper process for cleaning such floors is to wipe them 
every morning with a damp cloth and polish them with a 
floor-brush, or else to clean them by a broom with a cloth 
tied over the head, the beeswax or paraffin being renewed 
from time to time as necessary. This wet and dry rubbing 
process of cleaning is far less laborious than either frottage or 
scrubbing, and completely removes the dust and freshens the 
ward in the morning. Practically, with care, a well-laid oak 
floor, with a good beeswaxed surface, can always be kept 
clean by wiping over with a damp cloth and rubbing. An 
old-fashioned, simple method of sweeping a ward floor is to 
use tea-leaves sprinkled with carbolic acid ; these collect and 
retain the dust very efficiently. 

All ward floors should be scraped and repolished periodi- 
cally. 



CHAPTER XV. 

THE WARD UNIT {co7itinned). 

Ward Offices. 

The ward offices are of two kinds : — 

[a) Those which are necessary for attendance on the sick 
and for facilitating the nursing and administration of the 
wards, as the room for the medical man, the nurses' room, 
and ward scullery. 

{b) Those which are required for the direct use of the 
sick, so as to prevent any unnecessary processes of the 
patients taking place in the ward ; as, for instance, the 
ablution-room, the bath-room, the water-closets, urinals, and 
sinks for emptying foul slops. There should, in addition to 
the bath-room here mentioned, be a general bathing-establish- 
ment attached to every hospital, with hot, cold, vapour, 
sulphur, medicated, electric, shower, and douche baths, which 
are gradually assuming a prominent position in curative 
treatment. 

Hot and cold water should be laid on to all ward offices in 
which the use of either is constantly required, to effect 
economy of labour in the current working of the hospital. 

For convenience and economy of administration, when the 
wards are on two or more floors, lifts should be provided to 
carry up coals, trays, bedding, and patients. Miss Nightingale 
('Notes on Hospitals') estimates that a convenient arrangement 
of lifts and the laying on of hot and cold water economizes 
in attendance as much as one attendant to thirty sick. 



214 Healthy Hospitals. [ch. 

{a) Ward Offices connected with Nursing and Admitiistration. 

Surgeon s Room. — Wherever there is a medical school in 
hospitals it is advisable to have a surgeon's or physician's 
room, forming a part of the ward offices attached to the ward 
unit. This is the more necessary with detached pavilions ; 
but, on the other hand, one for every ward unit would add 
materially to the cost. The object is to have a place for 
necessary examination and in surgical cases for minor opera- 
tions. It should be light, airy, and if for the last- mentioned 
purpose, afford a floor space of not less than from 150 to 180 
superficial feet. 

Nurse's Room. — In some hospitals the nurse lives close to 
her ward ; in that case she should have a bed-room and a 
sitting-room. This plan is not desirable, as it is of importance 
for health that the nurse should always sleep and take her 
meals quite away from the ward air ; and at night the night- 
nurse would take her place. 

The nurse's sitting-room should be sufficiently large to 
contain a bed. It should be light, airy, and well venti- 
lated, as a cheerful room is a material assistance to a nurse. 
It is necessary to discipline that it .should be close to the 
ward door, and that it should have a window looking into 
the ward, so as to command it completely. If the nurse 
has two wards to supervise, her room should be placed 
between the two, with a window opening into each ; in any 
case it must be so placed as to afford supervision over the 
small wards forming part of the ward unit. 

Ward Scullery. — There should be a scullery attached to 
each ward, adjacent to or opposite the nurse's room, so as to 
be under her eye. 

The scullery should be supplied with complete, efficient, 
simple apparatus, for its various purposes ; there should be a 
small range for ward cooking, so that the nurse can warm the 
drinks and prepare fomentations, and a sink for washing up but 



XV.] The Ward Unit. 215 

not for slops, &c. The sink for washinf^ up and for cleaning 
utensils should be of a light colour to show when it is not 
clean, and of a non-absorbent material capable of being 
easily cleaned. It should have hot and cold water laid on, 
with taps affording a full supply, and a waste-pipe large 
enough to discharge rapidly, and trapped close under the 
sink. 

Care should be taken that the waste-pipes deliver into the 
open air over a trapped gully, so that there should be no 
direct communication between the waste-pipe and the drain, 
otherwise foul air is certain to find its way into the hospital. 
Shelves or racks should be provided for ward crockery, but it 
is undesirable to have many cupboards or closed recesses, 
as they become in time receptacles for dirt and rubbish. 
There should be no dark corners under the sink or anywhere 
in the scullery, and it should have ample window-space. The 
scullery should be large enough for the assistant nurses to 
sit in, and to have their meals comfortably, if required. 

There should be provided in connexion with the scullery, 
a separate place for keeping the necessary provisions such as 
milk, fitted with a refrigerator, but cut off from the ward air ; 
a miniature dairy receptacle outside a window, and with 
perforated sides, is a convenient arrangement for this purpose. 
Also a hot closet for airing clean towels and sheets. For foul 
linen it is undesirable to have any receptacle near the wards, 
or indeed in the hospital building. It should all be placed in 
galvanized iron receptacles, or trucks on wheels, and conveyed 
as soon as possible to the laundry. Ward-sweepings and 
refuse should similarly be placed in moveable receptacles, and 
taken out of the building with as little delay as possible ; 
structural provision is not advocated for the retention of these 
in or near the hospital. 

Brooms, brushes, pails, &^c. — There must be a closet for 
these cleaning appliances, but it must be very light and airy to 
prevent its becoming a receptacle for rubbish. 



2i6 Healthy Hospitals, [ch. 

Store for patients' clothes. — Patients' clothes are removed 
on their entering the hospital ; the linen, cotton, or woollen 
clothes are washed, and the cloth clothes disinfected by heat 
or otherwise. When they have been so treated it is generally 
convenient, as a matter of administration, to restore them 
to the care of the ward nurse. 

In this case it is necessary to attach a store to each ward 
unit. This store should be very well lighted, kept scrupu- 
lously clean, and supplied with racks, and numbered divisions, 
to allow of each patient's clothes being kept separately. 

A store for patients' clothes without direct window light is 
objectionable. 

The clothes should be taken out, unfolded, re-folded, and 
put away again at least once a fortnight to prevent moths. 

In an infectious hospital this arrangement will not suffice. 
The patient will wear hospital clothing while in hospital. 
His own clothes, after washing and disinfection, will go to a 
general store, adjacent to the discharge rooms. These rooms 
consist of waiting room and undressing rooms, opening in to 
bath rooms ; these latter open into dressing rooms connected 
with the discharge room on the other side. The patient 
leaves his hospital clothes in the undressing room, goes into 
the bath, and then passes on to the dressing room, where he 
puts on his own clothes, and is then discharged. 

(Jj) Ward Offices required for the direct tise of the Sick. 

The custom has been to place this, the second class of 
ward offices, at the opposite end of the ward to that occupied 
by the nurses' rooms, scullery, &c. This entails additional 
expense in the pipes for the supply of hot and cold water, 
and sometimes in that of the drains for the removal of refuse 
water. There is, however, no reason why they should be so 
placed with the present improved arrangements for the 
removal of foul water, and the construction of drains outside 
the buildings. 



XV,] The Ward Unit. 2 i 7 

Moreover, expense would be diminished if these appur- 
tenances were placed nearer to those of the first class. 

Ablution Room, Water-Closets^ &^c. — These ward offices of 
the second class ought to be as near as possible to the ward. 
but cut ofif from it by a lobby, with windows on each side, 
and with separate ventilation and warming, so as to prevent 
the possibility of foul air passing from the ward offices into 
the wards. When placed at the end of the ward, furthest 
from the entrance and nurses' room, they are best distributed 
at each side, so as to enable the ward to have an end window. 

In the Breslau Surgical Hospital and some other German 
hospitals, as well as in the Johns Hopkins Hospital, these 
ward offices are placed at the same end of the ward as the 
scullery, nurses' room, &c. ; but the arrangements in these 
hospitals leave something to be desired. M. Toilet's plan at 
Montpelier also places them centrally, and seems to cut them 
off more effectually than in the cases just mentioned. 

The principle which M. Toilet would appear to advocate 
most strongly is in the St. Denis Hospital; there he allows no 
air connexion between the w.c.'s and slop-sink, &c. and the 
ward and other ward offices ; he effectually cuts off the w.c.'s 
&c. by placing them in a detached turret-building on two 
or more floors, access to which is obtained on each floor by 
means of a light covered bridge arranged to impede venti- 
lation as little as possible. In the Women's Hospital, Euston 
Road, and in the new Derby Infirmary, the w.c.'s, lavatories, 
and bath-rooms are placed in detached turrets, separated by 
an air space from the ward blocks ; access being afforded by 
means of covered bridges. 

The diagrams (Figs. 26 to 34) show these and other 
arrangements for the ward offices. 

Adjacent to the ablution-room there should be a bath- 
room with one fixed bath supplied with hot and cold water. 
Terra -cotta when once warmed has the advantage of re- 
taining the heat longer than almost any other material and 



2i8 Healthy Hospitals. [ch. 

of being always cleanly, but it absorbs a great deal of heat 
at first. Hence when the bath is frequently used it is the 
best material ; but if the bath is seldom used, then copper is 
better, or polished French metal, which latter should be kept 
scrupulously clean or it acquires an offensive appearance. 
There should be no inclosed space round the bath, so that 
no dirt may accumulate ; a broad wooden bar round it affords 
all necessary support to the bather. 

A lavatory table of impervious material, such as slate or, 
what looks cleaner, common white marble, with a row of sunk 
white porcelain basins with outlet tubes and plugs, each basin 
supplied with hot and cold water, should be placed in the 
same compartment as the bath, but separated from it by a 
partition and door. It is a common mistake to place these 
lavatory basins too near each other, so that they cannot be 
used conveniently by patients standing abreast. Two feet six 
inches from centre to centre is a minimum distance. 

There should be a full delivery of water from hot and cold 
water taps ; and the waste-pipe should be large, to admit of 
rapid emptying. There should be a trap on the waste close 
under each basin, and each waste should deliver in the open 
air over a trapped gully. It is undesirable to have closed 
spaces under the basins, as they only accumulate dirt ; all 
parts under the ablution table^ and elsewhere, should have 
ample light ; nothing should be kept in these offices but what 
is required for constant use, and everything should be open 
to inspection and arranged for easy cleaning. All fittings 
should be light-coloured, as they then show any want of 
cleanliness. 

The waste-pipes, soil-pipes, and supply-pipes, both for hot 
and cold water, may usefully be painted in different colours 
so as to distinguish them at sight. There should be room 
for a portable bath for each ward, which should be provided 
with noiseless wheels, and hot and cold-water taps at 
a convenient height for filling ; and there should be a sink 



XV.] The Ward Unit. 219 

on the floor-level for running off the water out of the bottom 
of the bath after it has been used. 

Water-closets should not be less than two feet ten inches 
wide by four feet long. They should never be placed against 
an inner Wall, but always against the outer wall of the com- 
partment. A pan of a hemispherical shape, never of a conical 
shape, with a syphon, abundantly supplied with water to flush 
it out with a large forcible stream, is the best contrivance for 
the water-closet of a hospital. On the male side the urinal is 
always a structural difficulty, and it is only by great attention 
that it can be kept inoffensive. Probably moveable utensils 
standing on a light-coloured non-porous slab would be best. 

The sink for slops, bed-pans, expectoration-cups, &c., which 
should have a compartment of its own, adjoining the water- 
closets, should be a high, large, deep, round pierced basin of 
earthenware, with a cock extending far enough over the sink 
for the stream of water to fall directly into the vessel to be 
cleaned, and of a large size with an ample supply of water ; 
this sink should have a separate service arranged to flush it out 
like a water-closet pan. The space round it should be sloped 
into it either by means of a leaded or what looks cleaner 
a pottery surface, and there should be as few angles as possible 
to allow of accumulation of dirt. The space underneath 
should not be closed in ; if it is, the enclosed part will be 
made a receptacle for rubbish. 

The place for the retention of utensils, for the inspection of 
the medical man, is best arranged in a cupboard, with a door 
shutting it off from the lobby in which the w. c. and slop-sink 
are placed, but with a large grated opening to the outer air, 
and preferably a glazed flue may be led from it direct to above 
the roof: sometimes a perforated zinc receptacle for this 
purpose is fixed outside a window. 

Walls of ablution-rooms and water-closets should be covered 
with white glazed tile, slate enamelled or plain, or Parian 
cement ; plaster is not a good covering for them on account 



2 20 Healthy Hospitals. [ch. 

of their liability to be splashed, and of the necessity for the 
walls to be frequently washed down. 

The nurses should have separate private water-closets. 
They should not use those of the patients. 

There should also be water-closets for the patients who are 
well enough to leave their wards. 

Water-closets and the ablution-room should each have ample 
windows opening to the outer air, certainly not less in pro- 
portion than the wards. They should have shafts carried up 
to above the roof, to carry off the foul air, and ventilating 
openings to admit fresh air independently of the windows. 
Warmth should be supplied to them independently both of 
the wards and of the lobbies, which should cut them off entirely 
from the wards. The lobbies should also be carefully venti- 
lated by flues for extraction of air and by inlets for fresh air, 
and they should be well warmed. 

Care in these details is essential to prevent any of the air 
from these conveniences passing into the wards and thus 
becoming a source of danger to the patients, especially in 
cold weather. All woodwork, such as seats to water-closets, 
should be of non-absorbent wood. The floors, unless warmed, 
must be of non-absorbent wood, and the greatest care should 
be taken in the jointing. 

Drainage. — The following are the general principles to 
be observed with respect to the drainage of a hospital. 

(i) Drains should be made either of glazed stoneware 
pipes with cement joints, or preferably of strong cast-iron 
pipes jointed with carefully made lead joints, or with turned 
joints and bored sockets. In no case should a soil-pipe be 
built inside a wall. It should be so placed as to be always 
accessible. Junctions between pipes of different materials 
should take place outside the buildings. 

(2) The pipes should be generally 4 inches diameter. In 
rare instances need a drain-pipe for a hospital exceed 6 inches 
in diameter. 



XV.] The Ward Unit. 221 

(3) Every drain should be laid with true gradients, in no 
case less than j-J^, but much steeper would be preferable. 
When from circumstances the drain is laid at a smaller 
inclination, flush-tanks at the head and at intervals in its 
length should be provided. The drains should be laid in 
straight lines from point to point. At every change of level 
or of direction there should be reserved a means of access to 
the drain. Between these points the drains should be proved 
to be water-tight by plugging up the lower end of the drain- 
pipe, and filling it with water, provided always the extreme 
pressure in the pipes should not exceed 3 feet of head of water. 

(4) No drain should be constructed so as to pass under 
any part of a hospital building, except in particular cases 
where it is unavoidable. In such cases the pipe should be 
of strong cast-iron, laid in a straight line between inspection 
chambers outside the building on each side, and the length 
of drain laid under the building should be freely ventilated 
at each end, with a flush-tank placed at the upper end. 

(5) Every drain should be arranged so as to be flushed 
and kept at all times free from deposit. 

(6) Every drain should be ventilated by at least two 
suitable openings, one at each end, so as to afford a current of 
air through the drain, and no pipe or opening should be used 
for ventilation unless carried upwards without angles or hori- 
zontal lengths, and with tight joints. The size of such pipes 
or openings should be fully equal to that of the drain-pipe 
ventilated. 

(7) The upper extremities of ventilating pipes should be 
at a distance from any windows or openings, so that there will 
be no danger of the escape of the foul air into the interior of 
the building from them. 

(8) The soil-pipes from all water-closets, and waste-pipes 
from slop-sinks for urine, should be continued above the eaves 
of the house for ventilation, and there terminate, with the 
ends open to the air ; and if such ends be at or near any 



2 22 Healthy Hospitals. [ch. 

window of the house, it would be necessary to continue such 
pipes up to the ridge of the roof. Every such continuation 
should be of the full size of such soil or waste-pipes. The 
soil-pipe should terminate at its lower end in a properly 
ventilated disconnecting trap, so that a current of air would be 
constantly maintained through the pipe. 

(9) No rain-water pipe and no overflow or waste-pipe 
from any cistern or rain-water tank, or from any sink (other 
than a slop-sink for urine), or from any bath or lavatory, 
should pass directly to the soil-pipe ; but every such pipe 
should be disconnected therefrom, by passing through the 
wall to the outside of the building, and discharging with an 
end open to the air. 

(10) Waste-pipes from cisterns, sinks, baths, lavatory 
basins, &c. should be trapped close to the cistern, sink or 
bath or basin ; otherwise the deposit which takes place even 
from clean water would in time create an offensive smell. 

(11) All pipes for the removal of foul or the provision of 
fresh water should be carefully protected from frost. 

There should be an intercepting chamber between the 
drains from each building and the main drain of the hospital. 
The drains from operation room, post-mortem room, and 
mortuary, should especially be carefully intercepted. The 
main drain should be ventilated and arranged to be flushed 
independently. 

Proportion of Ward Offices to Wards. — These various offices 
will vary but little with the size of the ward ; that is to say, 
a ward of twenty beds will require nearly as large ward offices 
as one of thirty- two beds. The number of water-closets 
and lavatory basins depends to some extent on the severity 
of cases treated ; twelve per cent, of the number of beds 
may be assumed as a rough approximation in each case. But 
whilst three water-closets per ward will suffice for a ward of 
thirty-two beds, two at least will be required for wards con- 
taining eight to ten beds. The superficial area to be added to 



XV.] 



The Ward Unit. 



223 



the hospital in the case of wards of thirty-two beds for these 
appliances would be about 30 square feet per bed, whereas in 
wards of twenty beds each it might come to above 60 square 
feet per bed. 

The following table shows approximately for a few hospitals 
the superficial area of the space occupied by ward offices, 
passages, &c., exclusive of day or dining rooms, per bed in the 
ward unit. 



Hospital 


No. of Beds. 


Superficial Feet per bed. 


I. Eloi 


62 


30 


2. Tenon 


56 


( exclusive of 
^ ( staircase 


3. S. George's Union 


32 


20 


4. Bichat 


30 


18 


5. Johns Hopkins 


28 


64 


6. S. Denis 


16 


67 



This shows roughly how much cheaper large wards are 
than smaller ones in first construction. 



CHAPTER XVI. 

AGGREGATION OF WARD UNITS. 

The ward, with its ward offices as before described, is the 
unit or basis of hospital construction. It is a small hospital 
which would only require certain administrative additions to 
make it complete. It forms a basis for any hospital. It 
could be developed into a Cottage Hospital, an Isolation 
Hospital, a Children's Hospital, or indeed, under varied 
conditions of internal arrangement, into almost any other form 
of small hospital ; the principal ward being made larger or 
smaller according to the requirements of each case. 

And in addition to this, a large hospital of any required 
size might be formed by the addition of similar units. 

There are, however, two important considerations in reference 
to the number of wards which should be kept prominently 
in view, in designing a hospital. 

In the first place, the necessity of arranging the number 
of wards in proportion to the number of patients, so that 
in each year every ward shall be closed once for aeration, 
cleaning, and repairs. Such closing should preferably occupy 
one month, so that there should in large hospitals be one 
extra ward in every twelve. And in smaller hospitals there 
should be always one spare ward. This is a matter which 
is very much overlooked in the original design of a hospital. 
A main object of this resting is to flush the ward with 
air as we flush a drain with water; hence the object of 
having openings on floor levels which, if not used during the 



Aggregation of Ward Units. 



225 



occupation of the ward by patients, would be of great utility 
for the aeration of the ward. 

Secondly, it is always desirable, and indeed it is essential, 
in infectious hospitals, that probationary wards should be 
provided to receive supposed cases of infectious disease until 
a satisfactory diagnosis has been established. 

Johns Hopkins Hospiteil 




P/an or Site 
Scale 



4O0 soort 



-^< 



A . Administrative Offices. 

B. Private Paying Patients. 

C. Bathing Establishment. 

D. Dispensary and Drug Stores. 

E. Kitchen and Domestic Apartments. 

F. Nurses' Home. 
H. Sick Wards. 

/. Sick Wards. 



K. Isolation Wards. 

L. Lecture Theatre and Students' Building 

M. Out-patients Department. 

O. Mortuary and Post Mortem Room. 

P. Laundry and Wash-house. 

R. Chapel. 

6". Green House. 



Fig. 36. 



Many of the more recent forms of hospital units and 
their aggregation into hospitals are given in the admirable 
work of Dr. Mouat and Mr. Saxon Snell on hospital con- 

Q 




A. Wards. 

B. Orderlies Barrack Room. 

C. Corridor. 

D. Day Room. 

E. Orderly. 

F. Bath Room. 

G. Lavatories and W.C's. 



H. Yard. 
/. Med. Comfts. 
K. Kitchen. 
L. Larder. 
M. Surgery. 
N, Scullery. 
O. Staircase. 

Fig. 36 a. 



P. Lobby. 
Q. Open Porch. 
K. Wood and Coals. 
S. Cook's Room. 
T. Wine and Beer, 
V. Pack Store. 
W. Waiting Room. 



Aggregation of Ward Units. 227 

struction, and in Mr. Burdett's ' Hospitals and Asylums of 
the World.' 

The plan of the Johns Hopkins Hospital (Fig. 36) affords 
a good illustration of the arrangements of buildings on a site. 

Whilst the Johns Hopkins Hospital shows a carefully 
devised plan for a large hospital, the accompanying plan of 
the new Military Hospital at Holywood, Belfast, shows a 
convenient grouping of the several buildings required for 
a small hospital. 

This hospital is arranged to afford the necessary height 
of 13 feet for the wards and their appurtenances ; whilst the 
subsidiary accommodation, including the Day Room and 
Orderlies' Barrack Room in the main or ward building, is 
limited for economy to to feet high. 

The upper floor contains two wards similar to those on the 
ground floor and, in addition, a ten-bed ward over the Day 
Room and Orderlies' Barrack Room, opening from the 
staircase on a lower level. 

The upper floor of the administrative building contains the 
Hospital Sergeant's quarters, Linen Rooms, and other such 
stores. 

Aggregation of ward units in the construction of a hospital. — 
The principles upon which these units of ward construction, 
or, as they are generally termed, pavilions, should be arranged 
when aggregated are as follow : — 

(i) There should be free circulation of air around and 
between the pavilions. 

(2) The space between the pavilions should be exposed 
to sunshine, and the sunshine should fall on the windows 
and walls. The arrangement by which sunshine will always 
fall to the largest extent on the space between pavilions and 
also be distributed most evenly over the wall surface, is 
obtained in this country by placing the pavilions on a north 
and south line or axis, because the slanting rays of the sun 
fall in the morning on the eastern, and in the evening on 

Q2 



228 Healthy Hospitals. [ch. 

the western side. With an east and west axis one side of 
each pavilion and part of the area between the pavilions is 
sunless for most of the year : this might possibly have 
advantages for a hospital in- a southern climate, but in a hot 
climate, just as much as in a cold climate, direct sunshine 
is necessary to promote healthy conditions. A place from 
which sunshine is always excluded is never healthy. 

(3) The distance between adjacent pavilions should not 
be less than twice the height of the pavilion reckoned from 
the floors of the ground-floor ward to the eaves, if with 
a very sloping roof, or to half the height of the roof, with 
a steep roof. This is the smallest width between pavilions 
which will prevent the wards from being gloomy in this 
climate. Where there is not a free movement of air round 
the buildings, the distance should be increased. In the new 
wards of the Western Fever Hospital at Fulham, whilst the 
two-story fever blocks are placed 70 feet apart, the diphtheria 
blocks are placed 113 feet from the fever blocks. 

As regards the question of wards on one floor or wards 
superimposed in two or even more floors, it may be accepted 
that, so far as the sick are concerned, they would, as a rule, 
be better placed on one floor in a ward unit well raised 
off the ground without anything over them. These units 
could be entirely separate, or they could open out of a 
common open verandah or glazed corridor ; and if land is 
cheap, and the site fairly level, it is probable that such an 
arrangement might be more economical than building two- 
story buildings. The pavilions might be nearer together 
than in the case of wards on two floors, and consequently the 
distance to be traversed by the medical men on visiting the 
wards would be from 30 to o^^ feet horizontally between 
the pavilions in the case of the one-story hospital, as com- 
pared with ascending from 14 to 16 feet by a staircase in 
the case of a two-story building. On the other hand, the 
cost of drainage may be somewhat greater, and facilities for 



XVI.] Aggregation of Ward Units. 229 

supplying hot and cold water to the ward offices will be less, 
in the one-story hospital. 

On town sites it is sometimes absolutely essential to build 
hospitals as compactly as possible ; in these cases, whilst the 
first cost may be greater, the current expenses would probably 
be less in a building with wards on two floors provided with 
lifts and other labour-saving appliances. A new town hos- 
pital should not be commenced unless the funds admit of 
an area adequate to healthy construction. But where a town 
hospital has to be remodelled on an existing site, it may be 
necessary to accept special arrangements in order to mitigate 
some departure from entirely satisfactory hygienic conditions. 
The necessity for superimposed wards, which in some town 
hospitals cannot be limited to two floors only, would render 
a special construction of staircases advisable to prevent com- 
munication of air between wards. The proximity of a noisy 
street would require special arrangements in the foundation 
of the buildings containing wards, to prevent the patients from 
feeling the vibration of heavy drays, and might even compel 
a corridor system of ward construction next the street instead 
of the pavilion system in order to ensure quiet for the patients. 
But where space admits, the location of each single ward unit, 
or possibly a double ward unit ss a small separate hospital, 
is preferable to the aggregation of patients in large buildings. 
Unless connected together by means of covered corridors this 
would entail, no doubt, more exposur-e to nurses, attendants 
and doctors than their aggregation in palatial buildings ; 
but where nurses and attendants have been provided with 
proper protection against the weather, in going to and from 
the wards to the administrative buildings, such exposure has 
not been found injurious to health. 

Whilst separation of the ward unit has been the principal 
feature of modern hospital construction in Germany and more 
recently in the United States, the complete separation of ward 
units in this country has only been adopted in some of the 



230 Healthy Hospitals. [ch. 

Metropolitan Asylums Board and other Infectious Hospitals. 
In the aggregation and connexion of ward units, except under 
special circumstances, there should not be more than two 
floors of wards in a pavilion. If there are three floors 
or more, in addition to the increase of patients under one 
roof, the distances between the pavilions become very con- 
siderable if the rule, which ought to be absolutely observed, 
is adhered to, of placing the pavilions at a distance apart 
equal to at least twice the height of the pavilion, measured 
from the floor level of the ward nearest to the ground. 
Moreover, heated impure air from the windows of the lower 
wards has occasionally a tendency to pass into the windows 
of the wards above. Besides, when two wards open upon a 
common staircase^ there is to some extent, danger of a com- 
munity of ventilation. On these grounds it is not desirable 
that a hospital should have more than two floors of wards 
one over the other ; and the basement or lower story 
under sick wards should not be utilized for purposes such 
as cooking, &c., from which smells might penetrate into the 
wards. 

When possible, it is best not to continue the staircase into 
the basement. 

When there are as many as four wards, one over the other, 
the staircase becomes a powerful shaft for drawing up the 
impure air of the lower wards, and the upper part of the 
staircase therefore requires special care in ventilation to pre- 
vent impure air from penetrating into the upper wards. 

In the case of Fever Hospitals for the Metropolitan Asylums 
Board recently erected by Messrs. Harston, for two floors of 
wards, the objection to the staircase forming a shaft for 
impure air between the lower and upper ward has been met 
by cutting off the staircase entirely from the entrance to the 
lower wards. The pavilions are connected by means of a covered 
way consisting of a roof on columns. From this covered way 
there is a direct separate entrance marked A to the lower 



XVI.] 



Aggregatio7t of Ward Units. 



231 



Western ferer HoapLtal of 
Metrop Aaylums Board 



ward, whilst the staircase leading to the upper ward has 
a separate entrance marked B so arranged as to give access 
from the covered way only to the upper wards. An outside 
staircase is also pro- 
vided at the further end 
of the ward for escape 
in case of fire. 

Covered communi- 
cation between wards 
on the several floors of 
parallel pavilions in 
large hospitals is gene- 
rally obtained by a 
block of superimposed 
corridors, with a stair- 
case at each pavilion ; 
this interferes with sun- 
shine and circulation of 
air. To prevent com- 
munity of air between 
the two floors of wards 
in the Colchester Mili- 
tary Hospital the stair- 
case has been placed 
intermediate between 
the pavilions Fig. 38. 

It is, however, a 
defective feature in 
hospital construction 
to unite parallel ward 
units, which consist of 
two or three or more 

superimposed floors of wards, by solid corridors on each floor 
so as to form closed courts. 

Hence the communication between parallel pavilions should 




,„9 19 



Staircaee 
in event- oF 
Fire 

20 30 4-0 



eo 



Scale of Feet 
Fig- 37- 



232 



Healthy Hospitals. 



[CH. 



be arranged with as little interference as possible with the 
light and flow of air between the pavilions. 



Colchester Military Hospital. 






^^ — n 


























I-I 


iJ 



a 




a 




5ca/e. 

5 10 so 30 40 so 

1 t— I I 1 U.^:::^:.:^ 



100 r: 



A. Ward. 


F. W.C. 


B. Orderly. 


G. Balcony. 


C. Scullery. 


H. Foul Linen. 


D. Lobby. 


/. Corridor. 


E. Bath, Lavatory. 





Fig. 38. 



K. Store. 
L. Stairs. 
Zi. Upper ditto. 
M. Porch. 



The staircase leading to the two ward units in a double 



XVI,] 



Aggregation of Ward Units. 



233 



pavilion should break the air connexion between them. 
To effect this neither ward unit should in any way trench 
upon the staircase, which should be amply lighted, warmed 



War a 



Nur3e 



ca 



Scullery 



Bridge to \ 
A dja c ent Pq vilio n I 



Corridors 

rr 



Lift 



■ma/I] 



-VJ 



7111 ; '/ 1 i . '---•'i 
III I II 

Lii; I I I I 
-I'-l'jJIU I 



Corridors 



Bridge to 
Adjacenc Pavilion 



Nurse 



03 



Sculfdry 



Ward 
First Floor- 
Fig- 39- 



and ventilated independently of either ward. An arrangement 
of this sort has been adopted by Mr. Keith Young in the new 
Derby Infirmary. 

To secure the object above mentioned, the staircase should be 



234 



Healthy Hospitals. 



[CH. 



entirely detached, as shown in Figs. 39, 39^, and connected 
with all adjacent wards by means of light bridges ; an open 
bridge would be best, but it would probably be desired to 
have a roof and glazed sides, in which case it should not 



Corrt'dor d Feet Migh ' 

Leading to 
Adjacent Pavilion 




iiii 1 1 1 I I 
JuUi-iXL._J 

Lobby 



Nurse 



T3 fti-c: 

C3 



\Corridor8Ft.High 

j Leading to 

I Acfjacent Pavilion 



Scullery 



yVard 

Ground Floor 
Fig. 39 a. 



exceed 7 feet 6 inches or 8 feet in height, and be provided 
with ample cross-ventilation. 

The centre of the staircase would afford a space for two 
lifts, one for patients and attendants, the other, a small one 



XVI.] Aggregation of Ward Units. 235 

for food, coal, &c., both carried down to the subway in 
the basement. 

This detached staircase would largely discount one of the 
objections to superimposed wards and would probably be the 
safest arrangement for a town site when several floors of wards 
exist 

If a covered corridor unites the ends of pavilions on the 
ground floor only, its roof should not at most be carried above 
the floor level of the first-floor ward. For, whilst the floor of 
the first-floor ward would be from 14 to 16 feet above the 
ground-floor wardj it would be unnecessary for purposes of 
communication to give the corridor a greater height than 
7 feet 6 inches or 8 feet ; there is however this consideration, 
that if the top of the corridor is made level with the ward 
floors of upstairs wards, it affords a convenient terrace on to 
which the beds of patients can be wheeled, so as to allow 
them to lie out in the open air. But a more convenient place, 
because more sheltered from wind, would be afforded by a 
broad verandah in front of the end-ward window, or, as shown 
in Figs. 31 and 34, by a broad verandah running along the side 
of the ward. 

The communication on the upper-ward floors between 
adjacent pavilions would be effected by means of bridges, 
which might be open, or covered and with glazed sides^ as 
desired ; these would be supported on light columns, and 
would afford places on to which patients could be rolled 
out of the wards into sunshine if desired, and would allow 
of the free flow of air underneath. The girder support- 
ing the bridge could have ample depth above the floor 
of the bridge, so as to leave as much space as possible 
between the top of the lower corridor and the floor of the 
bridge for the free passage of air. At Antwerp, and at 
Mons, bridges connect the upper wards with the adjacent 
buildings. 

In the Women's Hospital in the Euston Road, of which 



236 Healthy Hospitals. [ch. 

Mr. Brydon was architect, in order to obtain the maximum 
of aeration on the restricted site on which the hospital is 
built, the connexions between the administrative buildings 
and the wards on the upper floors are all made by means of 
bridges, which admit of circulation of air underneath. 

The treads of a hospital staircase intended for patients 
should preferably be i foot wide by 4^-inch rise, and in no 
case should they exceed from 5| to 6-inch rise. There should 
be a handrail on each side. There should be a landing after 
every eight steps, for the easy ascent and descent of patients. 
There should be nothing combustible in or near the staircase. 
To prevent panic in cases of fire a subsidiary staircase at the 
opposite end of the ward may be advisable. This can be 
conveniently carried down from an open balcony in front of 
the end window of the ward. 

But if the wards are free from combustible material, and if 
superimposed wards are separated by fire-proof floors, the risk 
from fire ought to be small. It is, however, essential that every 
hospital should be provided with simple and easily-applied 
means for checking the spread of fire. Adjacent to every 
ward and on every floor hydrants with hose should be placed. 
There should also be a hand engine available, and fire buckets 
always kept filled ; extincteurs would also be useful. Glass 
grenades are questionable, as the pieces of glass from a 
grenade thrown on to a fire to extinguish a chimney on fire 
have flown back into the ward among the patients. It may 
be assumed that, whatever the apparatus, the members of the 
hospital staff should be accustomed to its use by periodical 
exercises. 

The service of a hospital with more than one floor of wards 
can conveniently be carried on by subways under the lower 
corridor connecting the ward units. The connection of the 
subway with the ward floors must be by lifts. It would 
probably be found more economical to have lifts of two sorts, 
one for carrying patients or attendants about 7 feet x 4 feet 



XVI.] Aggregation of Ward Units. 237 

wide, the other for coals, food, &c., about 2 feet 6 inches 
X 2 feet 6 inches. High-pressure hydraulic power is at present 
the safest and most convenient force for working lifts, but 
electricity may eventually take its place. 

The larger lift would bring up patients and take down the 
dead to the subways, whence the body would be conveyed 
to the mortuary. 

It has already been explained that there is a limit to the 
numbers which should be congregated under one roof But 
the limit may be safely made to depend to some extent on 
the nature of the cases. 

With military hospitals, into which in time of peace many 
slight cases are received, it was decided that as many as 136 
cases might be placed in one double pavilion, divided into 
two equal halves in such a way that the communication 
between the halves was cut ofT by through ventilation. Of 
course in time of war, with wounded men, other conditions 
would prevail. In town hospitals, where the cases are of 
a more severe character, a similar double pavilion would 
probably not contain above 80 to 100 beds. 

An increased size in any given hospital ought not to be 
determined by increasing the number of beds in any one 
building, but by increasing the number of units, each con- 
taining from 80 to 100 beds ; and the extent to which these 
units should be multiplied would, if the units have been 
properly constructed and arranged, be determined not so 
much by the number of patients as by considerations of 
economy in administering the hospital. 

At the same time it is not advisable to have very large 
hospitals. It would be more convenient to the inhabitants of 
a town to have two hospitals of 500 beds each, semng 
a particular district of the town, rather than one large 
hospital of ],ooo beds, which would after all only be convenient 
for one of the districts ; and in selecting sites and making 
arrangements for new hospitals it should be remembered that 



238 Healthy Hospitals. 

the actual area per bed required for a hospital should be 
increased in proportion to the increase in the number of beds ; 
thus if 80 beds per acre are assumed as the admissible number 
for a hospital of 250 to 400 beds, a smaller number of beds 
per acre should be adopted in the case of a hospital with 
1000 beds. 



CHAPTER XVII. 



ADMINISTRATIVE BUILDINGS. 



The accommodation for the wards must be supplemented 
by the arrangements for what is called the administration. 
But it is beyond the scope of these notes to enter very fully 
into this part of hospital construction. 

The position and general construction of the administrative 
buildings should be made quite subservient to the accommo- 
dation for the sick, and to the broad general principle that 
these buildings should not interfere with the circulation of 
the air around or the light of the wards. 

The first point is to consider what is the smallest amount of 
this subsidiary accommodation which will suffice, and to 
provide that amount, and no more. Many rooms mean many 
servants, much cleaning, and consequent additional expense. 

As already mentioned, the necessary subsidiary accommo- 
dation falls under, firstly, that connected with the admission, 
treatment, and discharge of the patients : secondly, that con- 
nected with boarding the patients : and thirdly, that connected 
with general supervision. 

(i) Rooms co7tnected with admission, treatment, and 
discharge of patients. 
Reception, examination, and discharge rooms. — These are 
required, however small the hospital may be. They are placed 
near the entrance. There is a waiting room, examination room, 
and patients' bath room. The doors of these should all be wide 
enough to admit of the passage of a stretcher on wheels. 



240 



Healthy Hospitals. 



[CH. 



In hospitals where the patient's clothes are taken from him 
on entering, and where he is supplied with complete hospital 
clothing, the linen clothes would be sent to be washed and 
the woollen clothes to be passed through the disinfection 
chambers, after which they would then be returned to the 
store, conveniently near the discharge room, labelled for 
delivery to the patient when he leaves the hospital. Whilst 
in the store they ought to be unfolded, examined, and refolded 
at least once a fortnight as a preservative against moths. 

In the case of Infectious Hospitals the discharge room con- 
sists of an undressing room where the hospital clothing is taken 
off and left, a bath room where the patient bathes, beyond 
which is a dressing room where the patient resumes his own 
clothes and departs. 





Section through rows 
seats in Operation The 


or 

SLtrt 


'. 






a/" 


0^ ~ 










/-'Jo 


'',-° 


>» 



Fig. 40. 



Dispensary and drug store. — The former should be in a 
fairly central position. Where there is an out-patient depart- 
ment it may be convenient that it should supply the latter 
as well as the hospital. It requires a still room fitted with 
necessary appliances next to it. 

The Splint Room should be conveniently placed with 
respect to the surgical wards and to the operation room. It 
should be light, and should have a small workshop attached, 
with the necessary tools for the work connected with splints, 
bandages, &c. 

Operating Room. — The doors should be double, of varnished 
oak or hard wood, about 5 feet wide, to allow ample room for 



:v]i.] 



A dministrative Buildings. 



241 



beds on wheels to be wheeled in and out. The floors should 
preferably be of marble terrazzo or of some substance which 
would not absorb the fluids that necessarily fall upon it. 
The lower half of the walls should be of some glazed or 
polished material, durable, easily washed or cleaned, and of a 



P/an or Operating Theatre 
Surgical KJinih j Gott/nge/i 




ig Mstrsa 



restful colour, which would not absorb light. The upper part 
may be of plaster, similarly coloured or painted. Operation 
theatres in small hospitals have sometimes had their walls 
entirely covered with sheets of glass. 

In the operating theatre of medical and surgical schools 
seats must be carefully arranged to enable the students to see 
over each other's heads when seated. 



242 



Healthy Hospitals. 



[CH. 



There should be ample light, and no dark corners where 
dirt or dust might accumulate, either under the seats or other- 
wise. There should be windows in the sides, and a large 
window, if possible, to the north as well as top lights, but the 
windows should be so distributed as to avoid glare. 

Figure 41 shows a plan of the operating theatre of the 



Section of 
Surgical Klinik 



Oporatino Theatre 
St Gottinger) 




Fig, 42. 

Chirurgische Klinik at Gottingen, which was completed at 
the end of 1889 : the section of the theatre is shown in Fig. 42. 

This theatre is of a half-elliptical form, and large enough to 
hold two operating tables at the same time. The section 
shows how light penetrates to every part. 

The students come in on the upper gallery, and the patients 
are brought in through the centre on the ground floor from 
the waiting room without encountering the students, and pass 



XVII.] Administrative Buildings. 243 

out to the room for patients operated upon, whence they are 
taken to their wards. 

There are vertical windows on the side. The principal 
window is to the north, and is 14 feet 6 inches wide and 
16 feet high : it is furnished with shutters, which can cover it 
nearly up to the ceiling, and thus if desired the whole 
light can be made to fall on the operating table from the 
ceiling. 

A semicircular form of operating theatre is sometimes 
preferred. 

It must not be omitted to mention that a room close at 
hand for the administration of anaesthetics is necessary ; and 
that it is convenient to place the room, for applications of 
plaster of Paris bandages, in connexion with the operation 
room. The tables and shelves for instruments, &c. may 
advantageously be made of glass or very hard wood, for 
cleanliness ; it is needless to say that the most scrupulous 
cleanliness should be observed in every part of the room. 

Adjacent separate wards are occasionally provided, either 
as resting wards or as wards for certain cases to remain in 
after operations. But in the more recent hospitals this 
practice does not appear to prevail largely. 

Special baths are becoming a recognized branch of hospital 
treatment, and these should be provided in addition to the 
baths required for each ward. 

These consist of medicated, vapour, Turkish, and electric 
baths, as well as permanent water-baths. 

They might with advantage be placed where they could be 
made available for out-patients as well as patients in the 
hospital. 

A dead-house and post-mortem room should be provided, 
quite outside and detached from the hospital : it should have 
a surgeon's room and dressing room, as well as a room in 
which the coffin would be placed previous to removal of the 
body. 

R 2 



244 



Healthy Hospitals. 



[CH. 



SneTCH PLAN OP CornoiNFD PoST-MonTtrM Rooms and MoRTUARf 

HAVINC PACll-ITies FOR INQUESTS . SuiTAate TOR HoSPITAU* 



111 
(0 



Public 

Entramco 



in QMAl-l. PROVIIiCI/M. TOYVN9. 

HospiT^u ■ ^1 BuiLoincs 




Ya.rd <?a Street 



Fig. 43- 



XVII.] Administrative Buildings. 245 

There should also be a waiting room for the patients' 
friends ; and the doors should be so arranged that the hearse 
can come in and go out unseen from the hospital. 

If the hospital has a medical school attached to it, it would 
be convenient that a post-mortem room, with dissecting 
tables, microscope room, a chemical, bacteriological, and 
physiological laboratory, a pathological museum and lecture- 
room, should be arranged in connexion with the mortuary. 

There should also be lavatories, room for hats and coats, 
dressing room, and general waiting room required for the 
students. These should be abundantly light and kept scrupu- 
lously clean. 

All the rooms in this section should be quite plain, and 
without projections or ornaments, which only form a resting- 
place for dust. 

In smaller hospitals, and especially in hospitals in country 
places, it occasionally happens that the holding of an urgent 
inquest occasions considerable trouble. This involves the 
viewing of the body, and unless facilities are afforded for the 
inquest near the hospital inconvenience results to the jury 
and others officially connected with it. 

This would be obviated by the plan shown in Fig. 43, 
from the design of Mr. Peach, architect. 

Out-patients Department. — Those hospitals which afford 
out-door relief require a dispensary for out-door sick as well 
as casualty rooms for surgical cases, but the latter would be 
used also for cases which would go direct into hospital. 

The out-patients' department is in reality a separate estab- 
lishment, and should always have an entrance separate from 
the hospital ; indeed, it might preferably be altogether 
detached, except for the convenience of the medical men and 
the school, and in order to have one drug store and one place 
for making up medicines. 

This department, and especially the waiting-room which is 
always a fertile source of impure air, should never be placed 



246 Healthy Hospitals. [ch. 

under the wards, nor in interspaces between wards, nor near 
the windows of wards. In fact, the whole department would 
be preferably detached and near the entrance gate; but it 
should be well ventilated and warmed and very light. In a 
General Hospital it would be convenient to place it near 
the Dispensary. 

There must be waiting rooms for males apart from females, 
each with separate entrances and exits^ and W.C.'s attached. 
A refreshment stall is desirable ; and in some hospitals 
a dining-room is appended for children and sickly patients. 

The number of examination rooms must be proportioned to 
the number of medical men who attend. They would probably 
include male and female surgical casualty rooms ; consulting 
and operating rooms for ear and throat ; a gynaecological con- 
sulting room ; ophthalmic examination room ; medical con- 
sulting rooms ; a room for massage and electric treatment ; 
and rooms for isolation, and for the temporary reception of 
insane or noisy patients, with beds. 

Each examination room should be well lighted and large 
enough for simple operations, and provided with necessary 
sinks, and hot and cold water laid on. Each should have 
a small dressing room with a double entrance, so that, when 
the patient has had to undress, the physician or surgeon may 
at once be left free for the next case. In some of the surgical 
departments operating and recovery rooms are necessary. 

There should be a microscopic room, and arrangements for 
darkening parts of the examination rooms or otherwise for 
ophthalmoscopy, &c. A small chemical and a physical 
laboratory should also be attached ; but these might be con- 
veniently placed in connexion with the dispensary, and be 
common to the other departments of the hospital. To this 
department lavatories for the physicians and surgeons would 
be attached. 

The walls, floors, fittings, &c., should be of some non- 
porous material ; there should be no projections for dust, and 



XVII.] Administrative Buildings. 247 

all the rooms should be light and be kept scrupulously 
clean. 

As already mentioned, the baths for treatment should be 
arranged so as to be available for out-patients. 



(2) Rooms connected with Boardi?tg the Patients. 

The kitchen and the provision and other stores, between 
which and the wards there is constant movement, should be 
as central as possible, so as to save labour ; but the kitchen 
should be cut off from any corridor connecting together 
the pavilions. 

In connexion with this department would be a receiving 
and weighing room for receiving the provisions, convenient 
larders, and other stores. 

The kitchen should be fitted up with adequate means of 
cooking rapidly and economically ; the cooking apparatus 
should be adapted to cook a variety of food, and to secure the 
greatest digestibility and economy in the nutritive value of 
food ; these are matters essential to the patients' comfort and 
recovery, and to economical administration. 

The kitchen should communicate with a large scullery 
attached for washing up ; the serving-room would give access 
to both. The food would be delivered from the kitchen into 
small wagons of non-conducting materials arranged to prevent 
any loss of heat ; and the dirty dishes and plates would be 
handed back through the serving-room to the scullery. 

In hospitals in towns, where the kitchen must be in con- 
nexion with the main structure, it has sometimes been 
placed on the top floor. This is the case with the new Liver- 
pool Hospital and the Hospital for Women in the Euston 
Road. The kitchen had been previously so placed in the 
Barnes Hospital at Washington, and in the New York Hos- 
pital designed in 1875. Surgeon-General Billings observes 
upon the former : ' The placing of the kitchen in the third story 



248 



Healthy Hospitals, 



[CH. 



of the hospital, which was the best feature in an otherwise 
poor hospital, was a decided success in more ways than one. 
The odours from cooking are almost entirely excluded from 
the building, although sometimes the lift which passes through 
the kitchen down to the dining room acts as a sort of air 
pump, and draws or forces some of the air from the kitchen 
down to the second floor.' 

A kitchen on the upper floor may have advantages in 
some respects on a restricted town site. With a system of 
lifts, the provisions received in an ofiice below would be con- 
veniently sent up, nor would there be any difiiculty in lowering 
all the food to the basement in small wagons designed to 
retain heat, and moving it in the subways to the pavilion for 
which it is destined. 

Reftise. — It is an axiom of hospital administration that no 
refuse of any sort should remain on the hospital premises. 

The refuse consists 
of— 

{a) Liquid re- 
fuse, including water 
from washing, slop 
water, &c. This 
would be removed 
by drainage. In 
connexion with this, 
provision must be made for catching the grease from the 
kitchen waste water, as shown in Fig. 44. A moveable pan 
placed under the sink, constructed on the same principle, 
would answer probably better. 

{b) Excreta should also be generally removed by drainage 
in any permanent hospitals ; and where it could not be con- 
ducted into an existing system, it should be applied to 
land — either by irrigation or intermittent downward filtration 
according to circumstances. In small country hospitals earth- 
closets might be made use of; but they require great care to 




Fi 



'g- 44- 



XVII.] Administrative Buildings. i/\^c) 

avoid nuisance, and the simpler they are in construction the 
better^. 

{c) Ashes. These would be removed by a contractor. 
id) Vegetable and animal refuse. Some of this refuse 
might be sold or given away ; but much of it would be 
best destroyed on the premises. 

{e) Refuse connected with treatment of the patients, not 
disposable in the drains. This latter class of refuse should be 
destroyed on the premises, and for this purpose there should 
be a destructor attached to every hospital in which refuse 
matter either connected with the wards or the kitchen depart- 
ment could be destroyed. 

In the Metropolitan Asylums Board Infectious Hospitals, all 
the kitchen refuse is destroyed instead of being sold, but this 
would not be necessary in an ordinary hospital. 

Figs, 44 a and 44 b show a plan and section of Crane's 
destructor used at the Western Hospital of the Metropolitan 
Asylums Board, which is simple and has acted efficiently. In 
cases where this class of refuse presents a difficulty in being 
burnt without smell, it may be necessary to draw the fumes 
into a tall chimney, after they have been passed through 
a thoroughly incandescent coke fire, and through a close box 
lined with lead and filled with small pieces of coke, which are 
kept sprinkled with water from a perforated pipe ; the fumes 
are drawn up through the coke into the chimney, and the 
water, after passing over the surface of the coke, is run into 
the drain ; this method of treatment removes smell. 

Lineal Stores. — The stores for bedding and linen should be 
as central as can be arranged, and have conveniences for 
receiving the linen and for storing it on dry racks and shelves. 
There should be a large, well-aired, well-lighted, well-warmed, 
well-arranged linenry and mending-room. 

Laundry. — The hospital laundry should be entirely de- 

^ Surgeon-General Marston, C.B., made a very good earth-closet for 
a field-hospital out of Kerosene tins. 



250 



Healthy Hospitals. 



[CH. 



tached from the hospital. Special care should be taken to 
make the buildings very airy and light, with ample means of 




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ventilation for removing the steam, which is heavily charged 

with organic impurity, and with ample space for the washers. 

There should be a separate room for the linen which 



XVII.] 



Administrative Buildings. 



251 



requires disinfection, attached to which should be the appur- 
tenances for the disinfection of dry or woollen clothes. 
There should be separate drying and ironing rooms. 







Servants. — The servants' bed-rooms should be airy and 
light. They would preferably be placed in a convenient 
central situation in the administration building. The male 



252 Healthy Hospitals. [ch. 

servants should of course be separate from the female servants. 
They could dine together in a common servants'-hall, but a 
sitting-room would be required for the women servants. 

(3) Rooms connected with General Supervision and Nursing. 

Apartments for the resident physician and surgeon and 
matron should not be under the same roof with the sick ; 
they would be best placed in a central position ; a bed-room 
and sitting-room for each would be required, with proper 
conveniences attached, and a dining-room for joint use. 

It might be convenient for the matron's sitting-room to be 
arranged for her to superintend what went on in the linen- 
and mending-rooms and in the kitchen department. 

The dispenser, if resident, requires a bed-room and sitting- 
room with proper conveniences attached. An office is 
required for the steward or purveyor, or financial officer. 
There would also necessarily be a room for the meetings of 
the governing body. The porter would require either a 
lodge or room at the entrance to the hospital, which would 
command the entrance and control all ingress and egress. 

Nurses. — The head nurse of a v/ard in some hospitals has 
her bed-room next the ward ; in that case she should always 
have a sitting-room adjoining. The meals should be taken 
in the common room. 

The nurses should preferably be lodged in a building apart 
from the hospital buildings. It would be advantageous that 
they should have to pass out of doors to reach their bed- and 
living-rooms. 

The head nurses or ' sisters ' should have a dining-room, 
and also a comfortable, well-furnished sitting-room. They 
work better in their wards if they are made comfortable : for 
sisters and nurses now-a-days are, or ought to be, educated 
women. It is undesirable that they should have to seek neces- 
sary amusement out of doors. Nurses should dine in the 
sisters' dining-room, but at a different hour; and in a large 



xvil] Administrative Buildings. 253 

hospital there would probably be required an additional 
dining-room for ward assistants. 

In hospitals with an establishment for training nurses, 
which every large hospital ought to have, the probationers or 
pupil nurses (in a proportion not exceeding one to every ten 
or twelve patients) would live in a ' home ' under the hospital 
roof, and under the direction of the hospital matron. 

The ^home' should consist of: — (i) Class-room and nurses' 
library — large, airy, and convenient. (2) One or two dining- 
rooms, in which sisters and nurses might also dine, and 
pantry adjoining. (3) Two rooms and an office for the 
'home sister' (class mistress). (4) One separate bed-room 
for each probationer — sufficient to contain press, table, chair, 
bookshelf, washstand, bedstead, and arm-chair. 

Each floor should have a bath-room and other conveniences, 
and baths in the proportion of one to eight persons ; the 
w. C.'s should be in the proportion of one to ten persons in 
addition to the W. C.'s for nurses adjacent to the wards. 
Baths and W. C.'s should be in separate compartments ; so 
arranged that when one was in occupation the use of the 
other would not be interfered with. 

Bed-rooms for probationers on night duty should be cut off" 
from the noise of the ' home.' There should also be provided 
— one sick room, one visitors' room, and servants' offices and 
bed-rooms for cook and other necessary servants with ade- 
quate conveniences. 

In all these buildings the same observations occur as in 
the wards and the appurtenances, viz. that the materials used 
in construction should be such as to be easily cleaned, that 
there should be no cornices or projections to catch dust, 
and that there should be abundance of light with absolutely 
no dark corners in the building, even under staircases, and 
no closets without good-sized windows. 



CHAPTER XVIII. 

Observations on some points connected with 
Hospitals for Incurables, Children's Hospitals, 
Convalescent Homes, and -Infectious Hospitals. 

It is beyond the scope of this work to describe special 
hospitals, but there are some points connected with the 
institutions mentioned at the head of this chapter to which it 
is desirable that the attention of a hospital architect should 
be called : 

(i) Hospitals for Incurables. 

(a) Children's Hospitals. 

(3) Convalescent Homes. 

(4) Infectious Hospitals. 

Hospitals for Incurables. — The cases treated by incurable 
hospitals are principally cases of chronic rheumatism, gout, 
paralysis, and various affections which cripple the limbs, &c. 
They do not require the same cubic and floor space that 
hospitals for acute cases may need. But they should afford 
warmth, and consequently covered places for exercise, baths, 
and the opportunity for patients lying in the sunshine. 

These hospitals, while treating cases within their walls, are 
no doubt productive of benefit to the community : but the 
system of granting pensions from the hospital funds to out- 
patients appears to have a questionable side, as there does 
not seem to be any guarantee or proof from the friends of 
the patients that the money given is spent for the purpose 
for which it is intended. 

Children s Hospitals. — The question of children's hospitals 



Hospitals for Inctirables, etc. 255 

is somewhat complicated. There are many diseases which 
occur in children of a lymphatic nature or scrofulous tendency, 
or which arise from latent tuberculosis, either inherited or 
otherwise, especially among the poorer classes, which being 
of slow and gradual development tend to fill our hospitals. 
These diseases might be overcome at an early stage by con- 
tinuous treatment in healthy surroundings. 

Whatever may be the destructive powers which recent 
science attributes to minute organisms in causing or ex- 
tending such diseases, it is at least certain that their powers 
of development are limited to surroundings which are favour- 
able to them. 

Air, especially sea-air, sunshine, abundant wholesome food 
such as milk or oatmeal, and cleanliness render the child's 
body less susceptible to such influences than it would be in 
its own wretched home ; and thus prevent the disease from 
developing into some kind of deformity or chronic infirmity 
which, if it does not terminate in phthisis, will limit or destroy 
the working power in after-life, and will probably be trans- 
mitted to a succeeding generation, to increase the already 
too large number of imbecile and helpless children. 

Hospitals for the treatment of such cases may be said to 
date from 1796 when one was opened at Margate: there are 
now several in England at various points of the coast ; but 
they are very limited as to the number of patients they 
can receive, and are entirely supported by voluntary aid. In 
France, on the other hand, there is a greater development of 
these hospitals, because — in addition to munificent private 
gifts — the Assistance Publique at Paris and the adminis- 
trators of hospitals in Lyons, Bordeaux and elsewhere, and 
in other cases the authorities in localities by the sea-side, have 
assisted in the establishment of institutions of this nature. 

There are in France marine hospitals for children estab- 
lished round the coast, at some dozen places, as for instance 
Berck-sur-Mer, Banyuls-sur-Mer, Avraches, Renne-Sabran, 



256 



Healthy Hospitals. 



[CH. 



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XVIII.] Hospitals for Incurables, etc. 257 

St. Pol-sur-Mer, Ver-sur-Mer, Cette, Cannes, &c., which 
contain in all probably from 1,800 to 2,000 beds. 

The statistics of these hospitals are stated to show that 
with a stay averaging 423 days, from 75 to 80 per cent, of the 
cases are entirely cured of scrofulous and tubercular diseases. 

The proportion of cures increases and the period for re- 
maining in hospital decreases when the children are sent at 
the commencement of the manifestation of the disease. 

The diagram annexed shows the arrangement at Banyuls- 
sur-Mer, which accommodates above 200 patients. It is 
situated on the sea-shore, where the children spend most of 
their time. They are accommodated in dormitories (in which 
the cubic space amounts to between 600 and 700 cubic feet), 
day-rooms, school-rooms, and refectory, and there is moreover 
an establishment for baths and hydrotherapeutic treatment. 
Dr. Leroux has recently published an interesting account of all 
these establishments, entitled ' Hopitaux Marins.' 

A hospital for children in a town is not advisable. It 
can only be looked upon as an adjunct to an out-patient 
department. 

Children, as a rule, are better cared for in their own homes 
than in a hospital, but in cases of accidents and acute diseases 
they may require special care and treatment which their 
homes would not afford ; such are appropriate cases for a 
town hospital. There is the additional consideration that 
the hospital provides means of affording clinical instruction to 
medical men. 

With regard to the question of providing hospitals in towns 
solely for children, it is of universal hospital experience that 
the intermingling of ages is desirable. 

Sick children can never be left alone for a moment. It 
might almost be said a nurse is required for every child. 

This is why in a general hospital it is much better for the 
children to be mixed as far as possible with the adults, and if 
judiciously distributed it does the woman in the next bed as 

s 



258 Healthy Hospitals. [ch» 

much good as it does the child, or the man as it does the 
little boy. 

If there must be a children's ward in a general hospital, let 
it be for the infants. 

If there is a separate children's hospital the age of admission 
on the female side would preferably include 15 years. 

A child's ward-nurse ought to feel for each child as if her 
happiness were bound up in its recovery. 

The general arrangements as to fresh air, &c., would follow 
those already described ; small special baths would be 
required. 

Children's water-closets must be self-acting, with no possibility 
for a child to fasten itself in or to communicate with another 
child when inside ; they should be well lighted night and day. 

A children's hospital should be provided with establish- 
ments for bathing, playing indoors and out, large garden 
grounds, gymnastic grounds and halls, both in and out of 
doors ; gymnastics should be under a professor, and out- 
patients should be always admitted to the exercises ; there 
should be school-rooms : and a ' sister ' should be appointed 
to superintend these places. It is desirable that singing 
in chorus be taught, and that a chapel should be provided 
for secular as well as religious teaching by a chaplain ; here 
only should the boys and girls meet. 

Before closing these observations on children's hospitals, it 
is desirable to add a few remarks upon school infirmaries or 
sanatoria. 

A boarding school of any size requires special provision 
for the reception and treatment of the sick members of its 
community. 

Broadly speaking, each school should possess — 

(i) Adequate accommodation for the reception and treat- 
ment of such of its inmates as may be suffering 
{a) from ordinary non-infectious illness, or 
[U) from the effects of accident and injury. 



XVIII.] Hospitals for Incurables, etc. 259 

(2) Separate accommodation for — 

{a) temporary and separate isolation for those who have 
been exposed to any of the several forms of infectious 
disease, but in whom the disease has not yet manifested itself ; 
{b) the treatment of those actually suffering from 
infectious disease. In this case there should be provision 
for isolating and treating separately from each other two or 
more different infectious diseases, should they occur simul- 
taneously. 

The amount of accommodation for sick or injured in a 
school depends to some extent upon the average age of the 
scholars. 

Amongst young children the incidence of infectious diseases 
is more frequent, whilst accidents and injuries will prevail more 
amongst older boys. 

It has been laid down by the medical officers of the Schools 
Association, that where the average age of a school does not 
exceed 12 years, the infirmary accommodation should be at 
the rate of 5 per cent, of the boarders ; and that with an 
average age of 15 years the allowance should be from 6 to 7 
per cent. 

Cases of infectious and non-infectious disease are best 
treated in separate buildings, and in order to provide adequate 
isolation for these, some addition to the above percentages 
would be necessary. 

For ordinary diseases and accidents the floor space should 
not be less than 100 square feet with about 1,300 to 1,400 cubic 
feet, according to the height of the wards ; the infectious wards 
should not afford less than 2,000 cubic feet of space, and 140 
to 1 60 square feet of floor space. 

The wards should vary in size from 2-bed wards upwards ; 
it would probably be more convenient in any school to limit 
the size of wards to 8 or 12 beds as a maximum. 

With a small separate hospital the accommodation, as to 
wards and ward offices with all necessary conveniences, would 

S 2 



26o Healthy Hospitals. [ch. 

follow, on a smaller scale, that which has been laid down for 
hospitals ; and such a building would require accommodation 
for a trained nurse as matron and other nurses and servants 
in proportion to its size. 

A surgery, with hot and cold water, cupboards and shelves 
for instruments and drugs ; and an examination room 
would be required, in which any boys requiring to see the 
doctor would be examined. A waiting-room, a day and 
dining-room, and an exercising ground or garden for con- 
valescents would be desirable, if the school hospital were at 
all large. 

In small schools where an establishment of this sort is 
impracticable, separate rooms with water-closet, slop-sink, and 
bath-room with hot and cold water laid on must be allotted 
(i) to ordinary cases, (2) to infectious cases, with additional 
rooms and a small ward kitchen for the special nurse who 
would be appointed to take charge. 

No refuse or foul linen should be retained on the premises. 

The several rooms should not communicate with each 
other : they should be continuously isolated if possible, by 
being approached by means of a separate staircase. 

The school drainage should be intercepted from the hospital 
drainage. 

Convalescent Homes. — It may be useful to make a few 
remarks upon these as adjuncts to a hospital. 

Every hospital should possess a convalescent home in a 
healthy open position and in a suitable climate. If possible 
it should be placed by the sea. 

It is an axiom that no patient (especially a child) should 
remain in hospital longer than necessary. Hence a con- 
valescent institution should be as like a home and as unlike 
a hospital as possible. 

But whilst there should be as little as possible in a 
convalescent home to remind the patients of a hospital, 



xviii.] Hospitals for Incurables, etc. 261 

yet, as relapses are occasionally unavoidable, it is necessary 
that some provision should be made for sick rooms and 
nursing. 

During relapses continual supervision is essential, con- 
sequently there must be two small wards, one for males and 
one for females, with the sister's room between them, looking 
into both, placed in a central position. 

In a convalescent home absolute separation of males and 
females is essential, especially as a safeguard against im- 
morality. 

To see the men and women patients going out walking 
together is to see that there is no discipline. 

Hence the best form of convalescent home is probably that 
of separate cottages holding each not more than 8 patients ; 
the males in one, and the females in another. 

The men and women should never meet except in the 
dining-room. 

All the cottages would be connected with the dining and 
day-rooms by means of a covered way or corridor. If the 
corridor is glazed and warmed, it would afford a place for 
exercise in cold or wet weather. 

The sleeping rooms of a convalescent home should have as 
efficient a system of ventilation as hospital wards ; but as they 
are occupied by night only, the cubic and floor space might be 
more restricted. 

The convalescents' beds maybe separated by curtains about 
6 or 7 feet high on a rod to be pulled quite back in the day- 
time. 

Patients on the female side should never be obliged to go 
to lavatories, a washhand-stand would therefore be provided 
for them within their compartments. 

Three or four beds is a good number for each convalescent 
room. Children are best placed to sleep in the rooms with 
women, if they can be so placed judiciously, otherwise they 
would require the supervision of a nurse at night. 



262 Healthy Hospitals. [ch. 

In the case of a child occupying the next bed to a woman, 
the curtain may always be drawn far back. 

There must be baths ; one bath-room to 8 patients is the 
smallest calculation. There should also be smaller baths for 
children ; close supervision whilst bathing is most important 
for children. A nurse or bathing-woman must always be 
present. 

An ablution-room would be provided for the males. 

The number of water-closets would be in the proportion of 
I to 8 patients. 

There should be a water-closet or two adapted for children, 
so that they should never be able to lock themselves in. 
These would also require the closest supervision. 

For occupation, men would be preferably employed in the 
garden under a gardener than at indoor trades in the day- 
room. 

When indoors the women should be occupied in household 
work as much as possible, at least on their own side, but never 
without permission from the medical officer, and under the 
surveillance of the sister. They may even do cooking, if 
with a hot plate in the kitchen ; but some who are able to 
walk, may not be able to use their arms. Of course such 
indoor work must never interfere with outdoor exercise. 
Some convalescents will want entire rest ; all must be pre- 
vented from damping their feet. Indeed, frequently the 
treatment will be entire rest with good food and fresh air. 

In the daytime feeble children should be with the women, 
but noisy ones must have a good airy play-room. A garden, 
not too pretty to play about in and make ' houses' in, is 
a great desideratum for children ; and they must not be 
mixed up with the men. 

The convalescent home would require supervision by 
a matron or sister, for whom a bed-room and sitting-room in 
a central position must be provided. Under her there would 
be the necessary nurses; these would best be distributed 



XVIII.] Hospitals for Incui^ables, etc. 26 



J 



among the cottages. The servants would be lodged near the 
kitchen and stores. A porter or gardener would live on the 
male side, or in a lodge near the gate. 

A kitchen with scullery, larder, &c., would be provided ; 
also a linen and mending-room, well lighted and warmed, and 
a small store-room. 

All refuse should be removed daily to a distance. 

A surgery would be necessary for the medical man who 
would periodically visit the institute. 

Infections Hospitals. — Although the general features of 
construction in infectious hospitals are the same as those of 
other hospitals, there are a few points connected with their 
general working in their bearing on the public, which it will 
be convenient to note. 

In the first place, Dr. Sykes, in his valuable treatise on Public 
Health Problems, says : ' Probationary wards should never fail 
to be provided in all infectious hospitals. It is sometimes 
extremely difficult to diagnose an infectious case correctly at 
the onset. In the meantime, the rest of the family or of the 
household in crowded dwellings may run great risk. The 
medical attendant is justified in advising isolation, and with 
proper dwelling accommodation this may be carried out ; he 
is not the less justified in advising removal to hospital where 
the accommodation is inadequate. It therefore remains for 
the hospital authorities to provide such means of isolation as 
may avoid both the retention of such cases in crowded dwell- 
ings and the infection of the patient, if after removal to 
hospital it should ultimately transpire that a non-infectious or 
less dangerous malady develops itself.' 

In the next place, the safety of the public requires that there 
shall be strict precautions observed as to the communication 
between the hospital employes and the outside world. 

It will be useful to show what those precautions are. 

It must be borne in mind that, while the public must 



264 Healthy Hospitals. 

continue to be jealously guarded not only against actual risk, 
but even against apprehension, vexatious and unnecessarily 
irksome restrictions ought not to be lightly imposed. 

The precautions which are adopted in the hospitals of the 
Metropolitan Asylums Board to secure these objects are 
classed under the following heads, viz. : (i) Visitors to Patients; 
(2) Staff ; (3) Patients' Letters ; (4) Disinfecting Machines ; 
(5) Destruction of Refuse, &c. 

(i) Visitors to Patients. The following regulation is in 
force at the present time, viz. : — 

Visitors will be required to wear a wrapper (to be provided 
by the Board) covering their dress and head, when in the 
wards, and to wash their hands and faces with carbolic soap 
and water before leaving the hospital, or to use such other 
mode of disinfection as may be directed by the medical 
superintendent. 

(3) The Staff. — No member of the staff, except when 
employed on ambulance duty, and messengers specially 
named for outdoor duty, is permitted to leave the hospital 
premises without having first changed his or her uniform, 
clothing, and stockings. No member of the staff going out 
with the intention of sleeping away from the hospital is 
permitted to leave the hospital without having first changed 
all his or her wearing apparel, and, except in case of ex- 
emption by the medical superintendent or matron, taken 
a bath. 

Subordinate officers, upon leaving the service of the Board, 
must satisfy either the steward or the matron that their 
clothing has been cleansed and disinfected, and that they 
have taken a bath. 

(3) Letters. — Patients' letters are baked before being posted. 

(4) Disinfecting Machines. — All the hospitals are provided 
with a super-heated steam disinfecting machine of modern 
type. 

(5) All refuse is destroyed. 



CHAPTER XIX. 



LYING-IN INSTITUTIONS. 



However great is the necessity for ventilation, freedom 
from contamination of air, and absolute cleanliness in the 
medical and surgical wards of a general hospital, it may be 
safely asserted that these necessities are tenfold greater in the 
wards of a lying-in institution. 

The great susceptibility of lying-in women to poisonous 
emanations, and the excessively poisonous emanations from 
lying-in women, constitute a hospital influence on lying-in 
cases brought together in institutions, second to no influence 
we know of exercised by the most ' infectious ' or ' contagious ' 
disease ; and yet the raison d etre of lying-in wards is that 
they shall be continuously occupied by a succession of cases. 

The conditions of hospital construction which have led to 
the greatly diminished mortality in recent years in these 
institutions appear to have been due to the greater isolation 
and separation of the cases. 

Inspector-General Massy, C.B., in a report to the Army 
Medical Department in 1869^ mentions a small lying-in hut 
hospital at the Colchester Camp, used exclusively for lying-in 
women. It was an ordinary wooden hut ; had a nurse's room 
at either end ; and the centre was divided into four small 
wards for one patient, each 10 feet, by 9 feet 10 inches, by 
10 feet. Ablution was performed in the wards; there was 
no water-closet in the ward, and the excreta were at once 
removed by hand. In five years 252 women were confined 
in this hospital without a single death. 



266 Healthy Hospitals. [ch. 

At Waterford the lying-in hospital consisted of a small 
house, in which one ward was used for the delivery of patients 
and two rooms received four beds each. (There were two 
such wards.) The mortality was i in 1328 in a period of 
23 years. 

These hospitals seem to have owed their immunity from 
disaster to the limited number of cases accommodated at one 
time in the hospital, and to extreme care in management. 

The Hospital Tenon has provided a small establishment 
containing a separate ward for each lying-in patient. 

The wards occupy two floors ; each ward is entered through 
a small lobby from an open gallery, so that there is no air 
communication between the wards. The floor space in each 
is about 150 superficial feet, and the ward is nearly 10 feet 
high ; the floors are of cement or of marble terrazzo. Each 
ward has an ordinary casement window in the side opposite 
the door, and an open fireplace. Opening out of the entrance 
lobby is a small scullery with sink, &c. Hot and cold water 
is laid on to a fixed wash-hand-basin in the ward. 

The matron has a duty-room at the end of the gallery on 
each floor, with which each patient can communicate by 
means of an electric bell. 

After each occupation the walls of the room are scraped 
and whitewashed. 

In the system adopted at the Lying-in Clinical Institution 
in Berlin, a special room is provided into which the patient is 
taken for the delivery, and then is taken back to her ward. 
The annexed Figure 46 shows a small portion of this establish- 
ment, which will suffice to explain the general arrangements 
of the lying-in wards. 

The wards are in separate pavilions, and contain 4, 3, and 
2 beds each. 

But whatever be the structural arrangement, success 
depends on cleanliness in the nursing ; all the architect can 
do is to facilitate cleanliness. In the Tenon Hospital, as well 



XIX.] 



Lying-in Institutions. 



267 



as in the Berlin Hospital, the most scrupulous cleanliness is 
observed, and the delivery-room and the walls and ceilings of 
the wards are frequently scraped and whitewashed. 

The following summary of the principles which should be 



Lying-in Hlinik, Berlin 




mrrnHd 



GQMistrea 



1. Ante-Room. 

2. Nurses' Room. 

3. Bath Closet. 

4. Students' Room. 



5. Ward, 4 beds. 
5". Ward, 3 beds. 

S*". Room for Midwives. 

6. Delivery' Room. 



Fig. 46. 



observed in constructing these institutions is reproduced from 
Miss Nightingale's notes on lying-in hospitals : — 

Lying-in institutions must be in the immediate neighbour- 
hood of great towns or centres of population. 

There should never be more than four beds in a ward, 
or single-bed wards might be arranged in groups of four. 
Also, it must always be borne in mind that four beds mean 
eight patients. Including the infant, there are two patients to 
each bed to use up the air, which is besides used up by 
a necessarily far larger number of attendants than in any 
general hospital. 

The general arrangement suggested is shown in Fig. 47. 

There should be two floors, or eight beds at most in 
a pavilion, but it would be preferable to have wards on one 



268 



Healthy Hospitals. 



[CH. 




A. Administration. 

B. Kitchen and Stores. 

C. Delivery Pavilion 

with curtain di- 
visions. 

D. Ward Pavilions. 



Fig. 47- 



XIX.] Lying-in Institutions. 269 

floor only. If on two floors, it is desirable that every alternate 
pavilion should consist of a ward on one floor only, unless the 
pavilions be so far apart as to cover an extent of ground 
which would make administration difficult. 

The minimum of ward cubic space for a lying-in woman, 
even where the delivery ward is, as it ought always to be, 
separate, is 2.300 cubic feet in a single-bed ward, and 1,900 
cubic feet, per bed, in a four-bed ward. In wooden huts, 
where the air comes in at every seam, this cubic space 
may be less. 

As it is a principle that superficial area signifies more than 
cubic space, the surface of floor for each bed should not be 
less than 150 square feet per bed in a four-bed ward, and in 
a single-bed ward not less than 190 square feet, because this 
is the total available space for all purposes in a single-bed 
ward. This space has to be occupied, not only by the lying-in 
woman and her infant, and perhaps a pupil midwife washing 
and dressing it at the fire, but often by the midwife, an 
assistant, possibly the medical officer and pupil midwives. 
In a four-bed ward there is space common to all the beds. 
There should be two beds and two windows on each side of 
the four-bed ward. 

In a single-bed ward the bed should not be placed directly 
between window and door ; and it must never be in an 
angle ^. There must be room for attendants on both sides of 
the bed. 

There should be two delivery wards for each floor of a lying- 
in institution, so arranged and connected under cover that the 
lying-in women may be removed after delivery to their own 
ward. And for this purpose the corridors must admit of being 
warmed during winter, especially at night, so as to be of 
a tolerably equable temperature. 

^ It may be mentioned here that pying the angles of wards was reta- 
in one Lying-in Institution the tively much worse than that of the 
medical record of the beds occu- other beds differently placed. 



27b Healthy Hospitals. [ch; 

Unlimited hot and cold water should be laid on day and 
night ; a water-closet sink, bath sink, clean linen, must.be close 
at hand. 

The delivery ward ought to be separate in every lying-in 
institution ; it must be separate in an institution of more than 
four or five beds, though in separate compartments. 

The delivery ward should be so lighted and arranged that 
it can be divided, by curtains only, into three if not four 
compartments, with one window to each bed. 

The curtains, of washing material, are only just high enough 
to exclude sight, not high enough to exclude light or air, and 
are made so as to pull entirely back when not wanted. Each 
area enclosed by the curtains should of course be sufficiently 
ample for pupils, attendants, and patient ; also for a low truck 
on broad wheels covered with india-rubber, to be brought 
in, on which the bedstead with the clean warm bedclothes 
is placed, and the newly-delivered woman conveyed to her 
ward. 

Every delivery bed should stand in a superficial area of not 
less than 200 square feet, and a cubic space of not less than 
2,400 cubic feet. 

Each delivery bed should have window light on either 
side, and also ample passage room all round and on both sides 
the bed. Care should be taken that no delivery bed should 
stand exactly between door and window, on account of 
draughts. 

The reason why there must be two delivery wards for each 
floor of a lying-in institution, to be used alternately, one ' off ' 
and one ' on,' is, that one delivery ward on each floor must be 
always vacant for thorough cleansing, lime-washing, and rest 
for a given period, say month and month about. 

Newly-delivered women cannot be removed from one floor 
to another. 

The position of the delivery wards should be as nearly as 
possible equidistant from the lying-in wards, and should be 



XIX.] Lying-in Institutions. 271 

such that the women in labour, on their way to the delivery 
ward, need not pass the doors of other wards. 

A separate scullery to each delivery ward is indispensable, 
such scullery to be on at least an equal scale to that of ward 
sculleries. Hot and cold water to be constantly at hand, 
night and day. A sink-bath is desirable for immediately 
immersing soiled linen from the beds and the like in water. 

The scullery of the delivery ward should contain a linen- 
press, small range with oven, hot closet at side of the fireplace, 
sink with hot and cold water, &c. A small compartment 
should contain a slop-sink for emptying and cleansing bed- 
pans, and a sink in the floor, which is intended for filling and 
emptying a portable bath. 

Beyond the scullery, so as to be as far removed as may be 
from the traffic of the main corridor and the noises of the 
delivery ward, should be the bye-ward, with not less than 
2,100 cubic feet of contents. One of such single-bed bye-wards 
should be attached to each delivery ward, for an exhausted 
case after delivery, till she is able to be moved to her own 
ward. 

All that has been said as to the necessity of impervious 
polished floors and walls for hospitals applies tenfold to 
lying-in institutions, where the decomposition of dead organic 
matter, and the recomposition of new organic matter, must 
be constantly going on. 

It is this, in fact, which makes lying-in institutions so 
dangerous to the inmates. 

And it may be said that the danger increases in a geometrical 
ratio with the number of in-cases. 

With respect to the sculleries, lavatories, and water-closets 
of the other wards it must be borne in mind that the necessary 
consumption of hot and cold water is at least double or triple 
that of any general hospital. Sinks and water-closet sinks 
must be everywhere conveniently situated. 

There should be a scullery to each four beds ; and the 



2/2 Healthy Hospitals. [ch. 

scullery needs to be much larger and more convenient than in 
a general hospital. All the ward appurtenances, scullery, 
lavatory, &c., should stand empty for thorough cleansing, 
when the ward to which they belong stands empty in rotation 
for this purpose, and should not be used for any other 
ward. 

Therefore, for each four-bed ward, or group of four one- 
bed wards, or for each floor of each pavilion, there must 
be one scullery, with a plentiful and unfailing supply of 
hot and cold water, with sinks and every convenience. The 
reason of this is twofold : — 

(i) To allow each scullery, with the other ward offices, to 
be thoroughly cleansed and whitewashed with its own group 
of four beds. 

(2) The work in a scullery and in all the other ward 
appurtenances day and night, night and day, is many-fold 
that which it is in a general hospital scullery. 

In a lying-in hospital the infants, most exacting of all 
patients, must frequently be in the scullery. 

Even under the very best circumstances there are many 
lying-in cases among weakly women where the mother's state 
is such as to render it necessary for a * crying ' infant to be 
washed and dressed elsewhere than in its mother's ward. 
These infants are best washed, in that case, in the scullery, 
which should be so arranged that infants can be washed and 
dressed without being exposed to a thorough draught, and 
that nurses and babies may not be hustling one another. 

There must be a good press in each scullery; in which 
a supply of clean linen and other necessaries will have to be 
kept. 

Besides this, general hospital patients ought never to be 
allowed to enter the scullery. 

Fixed baths are not necessary. But there must be the 
means for filling with hot water moveable infants' baths at all 
hours at a moment's notice. 



XIX.] Lying-in Institutions. 273 

There should also be a moveable bath for each ward for the 
lying-in women, with the means of supplying it with hot and 
cold water and for emptying it. Lying-in patients are not 
able to use either fixed baths or lavatory. 

Glazed earthenware sinks should alone be used, as being by 
far the safest and cleanest. 

No dispensary, or dispenser, is needed in a lying-in 
institution. 

A medical officer's room is necessary. The medical officer 
is not resident. 

A waiting-room is necessary. There must be a room where 
the head midwife can examine a woman. 

A segregation ward is necessary, completely isolated, where 
a sick case, brought in with small-pox, erysipelas or the like, 
could be delivered and entirely separated from the others ; 
and a ward to which a case of puerperal fever or peritonitis 
could be transferred. 

The segregation ward must have a nurse's room, and other 
necessary ward adjuncts, such as sink, slop-sink, &c. 

The question may, however, arise whether an infectious case 
originating in a ward should be removed from the ward, or 
whether all other occupants should be removed : and, indeed, 
it would always be advisable in Lying-in Hospitals of any 
size to provide for one ward to be always at rest ; such an 
arrangement would meet emergencies of this kind. It is also 
frequently desired by medical men, in order to meet symptoms 
suggestive of possible blood-poisoning, to surround the patient 
with fresh air, or, as it were, to flush her with fresh air. To 
this end a verandah would be a convenient adjunct to a ward ; 
indeed, a balcony on to which a patient could be moved 
into the open air may sometimes offer less risk in such circum- 
stances than the enclosing walls of a ward with its floor and 
furniture. 

It has, no doubt, been found that domiciliary confinements 
have generally afforded better results than those in hospitals ; 

T 



2 74 Healthy Hospitals. 

but experience shows, on the other hand, that with adequate 
attention to structural arrangements, especially if combined 
with absolute cleanliness, the Lying-in Hospital ought to 
produce results scarcely less favourable than the home ; 
and the hospital is certainly of manifest advantage for 
difficult cases. 



CHAPTER XX. 



REMARKS ON TEMPORARY STRUCTURES, 
AND CONCLUSION. 

Before closing these observations upon the construction of 
hospitals, it may be desirable to say a few words upon move- 
able hospitals. 

The argument has been often advanced that it would be 
preferable for all hospitals to be of a temporary character, 
so that the materials of which they are composed could be 
periodically burnt and new hospitals constructed. 

This argument has great force in the case of buildings 
constructed like many of those which exist in our principal 
towns. That is to say buildings, which in many places 
will be found suitable for the collection of organic matter 
under conditions favourable for decomposition^ and where a 
nidus is afforded for the development of organisms whose 
presence is assumed to be a concomitant of diseases. There are 
few hospitals in this country the interstices of whose floors, 
skirting boards, walls, and ceilings are not filled with organic 
matter in such a condition. No doubt walls can as a rule 
be scraped and plastered. But it would not be safe to restore 
such buildings without removing floors and ceilings, and with- 
out scraping and replastering the walls in such a manner as 
would be nearly tantamount to a rebuilding of the structure ; 
and there would still remain the chances of pollution from 
the long occupation of the ground. 

On the other hand, in the case of hospitals constructed on 
the principles laid down in this treatise — with that destroyer of 

T 2 



276 Healthy Hospitals. [ch. 

organisms, sunlight, penetrating to every part — with impervious 
floors, walls, and interspaces between buildings, in which there 
are no dark places for the lodging of impurities, the same 
conditions would not prevail, and a long occupation with 
periodical emptying, cleansing, and aeration of all parts, both 
in the occupation of the patients and otherwise, would keep 
the building in a hygienic state. 

On these grounds with a hospital which is intended to 
have any degree of permanence, or which is certain to be 
used at recurring intervals, as is the case with infectious 
hospitals, a brick building is preferable to one of wood or 
to a moveable hospital. 

In regard to temporary hospitals in towns there is the further 
consideration that sites for temporary occupation would be 
difficult to obtain at short notice ; wooden structures would 
be liable to fire ; iron structures would be hot in summer and 
cold in winter. Hence the most practicable plan is to have 
permanent structures for town hospitals adequate to meet the 
needs of the urban population, who would thus be secure of 
being treated with the best available professional skill ; and to 
supplement these hospitals by sanatoria in the country, to 
which convalescing patients could be moved. 

The moveable hospital is of course a necessity in war, but 
when it has been applied in this country by local authorities to 
meet outbreaks of infectious disease, with the idea that it might 
be taken to, and erected near, the locality of such an out- 
break, it has been found, first, — that time is required to 
obtain and prepare a site with necessary adjuncts of water 
and provision for refuse : and, secondly, that even if the 
materials were stored ready, some further time is necessary 
to erect and prepare the hospital for occupation, all of which 
operations postpone very considerably the date at which the 
hospital would be available for the reception of sick, and 
this necessary delay causes more inconvenience than would be 
experienced by carrying the patients a reasonable distance in 



XX.] Temporary Structures, and Conclusion. 277 

a properly appointed ambulance to a permanent hospital in 
some fixed position. 

The subject of moveable hospitals for purposes of war 
assumed prominence during the wars of the last thirty to 
thirty-five years largely through the efforts of the managers 
of the Red Cross Society. The principle was laid down, 
and has practically been accepted by governments, that if the 
soldier has the right to receive the best equipment to enable 
him to fight when he enters the field of battle, he has equally 
the right to expect the best care which surgery and medicine 
can afi"ord, if he has the misfortune to be wounded on the 
field of battle. 

The late Empress Augusta of Germany, who took so 
strong a personal interest in the solution of the question, 
off"ered prizes at the Antwerp Exhibition of 1885, and again 
in 1889 at Berlin, when not only buildings but appliances of 
all sorts for fitting them up were exhibited. 

The exhibition was based upon the assumption that the 
arrangements for aid to sick and wounded in war cannot be 
satisfactory unless they are made quite independent of the 
chance resources which may be found in the neighbourhood 
of a field of battle. 

The basis laid down was that the unit of accommodation 
should provide for 60 patients in moveable hospital huts, with 
accommodation for the necessary staff", viz. % medical men, 
1 subordinates, i cook, and 6 attendants for service on the sick. 

The programme assumed that three huts about 50 feet 
long and 16 feet wide would each accommodate 20 sick, 
and that two additional huts would accommodate the personnel 
and the necessary administrative requirements. 

These were fitted up in every detail with moveable articles re- 
quired, whether for the patients or for providing for their wants. 

It is beyond the province of this treatise to discuss the 
details of this question, which, moreover, would require much 
space. 



278 Healthy Hospitals. [ch. 

The hospitals which may be required in the rear of an 
army or at the base of operations would usually be reached 
by the aid of railway transport, and would possess a character 
of greater permanence. 

A few remarks upon the materials used in such quasi- 
permanent buildings will not be out of place. 

These materials are generally corrugated iron, wood, 
Willesden paper or oiled canvas on wood frames. 

As regards iron, it has the great defect for hospital purposes 
of being hotter and colder than other material, it must there- 
fore be lined with wood, and the interspace packed with some 
non-conducting material. Sawdust is not desirable, as it may 
decompose ; slag cotton is preferable, because it contains no 
organic matter. But iron has the further defect of being 
impervious to air. One of the chief advantages of a 
temporary hospital of wood is that its walls are permeable to 
air at all points ; but the walls must be made double, and 
if in a cold country the interspace should be filled in by 
a porous material. It was the permeability to air and the 
porosity of the walls which proved the chief element in 
the comparative healthiness of the hospital huts erected 
in the American War of Secession and the Franco-German 
War of 1870-1871. 

The paper or oiled canvas types of temporary moveable 
hospitals, which have attained to some degree of use by 
various local authorities in England, are the Daeker or 
Ducker. They consist of a waterproof material stretched 
upon wooden frames which are of definite shapes and 
numbered so as to be put up rapidly and form a weather- 
proof hut ready for patients. But others and at least equally 
convenient forms were shown at the exhibitions of portable 
huts for military purposes already mentioned. 

Although it is beyond the province of this work to 
enter into the details of this class of hospital, it may be 
observed that British troops have generally had to provide 



XX.] Temporary Structures, and Conclusion. 279 

for a hot climate rather than for that of the continent of 
Europe. 

Surgeon- General Marston, C.B., suggested one of the best 
forms of hut for affording protection against heat in summer. 
The object was to make as near an approach as possible to 
the condition of a person provided with a large thick umbrella 
as a protection against the sun or rain ; that is to say, the 
roof should be of such material and construction as to exclude 
the heat of the sun's rays. The hut should be provided with 
verandahs, and capable of free ventilation all round ; as well 
as shelter from wind when desired. 

There are certain other conditions which it may be well to 
summarize. 

The roof should be non-conducting. For a very hot climate 
cork slabs covered with waterproof Willesden paper were 
used ; under this was an air space, below which was a ceiling 
formed of inch boards laid with narrow interstices to allow 
of the circulation of air from the ward, and also air was 
admitted at the eaves, between the ceiling and the roof, near 
to the ridge ; ventilating tubes were carried from this air- 
space through the roof. 

This arrangement of roof was suitable for hot weather, 
because if the air in the interspace were confined, it would 
become very hot ; therefore circulation of this air was de- 
sirable. But for cold weather in order to retain the heat it 
would be advisable that the interspace should be closed so as 
to allow of no change of air. Therefore in such cases the 
ceiling should be fitted close, the admission of air at the eaves 
should be stopped, and the tubes should be carried from the 
wards through both ceiling and roof, and thus the air in the 
interspace would form a cushion to retain heat. 

The temporary wards for a hot climate had walls boarded 
to a height of 4 feet from the floor level, and to a depth of 
2 feet from the top (the bottom board at floor level being 
hung to open outwards); between these boarded parts the 



28o 



Healthy Hospitals. 



[CH. 







^^^" 



50.C 



Qkift- 







XX.] Temporary Structures, and Conclusion. 281 

wall was formed of matting which could be rolled up when 
desired. 

The roof was continued over the walls to form a verandah 
7 feet 6 inches wide all round, on to which patients' beds 
could be wheeled. At one corner of the verandah the earth 
closets and ablution rooms were placed, and being railed off 
from the verandah by an open railing, there was no air 
connexion between them and the ward. 

The ward floor and verandah were on the same level and 
raised from 18 inches to 2 feet off the ground, with free 
circulation of air underneath. 

The plan and elevation of this hut is shown in Fig. 48, 
and fuller particulars will be found in the Report of the 
Army Medical Department for 1884. The main arrangements 
shown would — with the necessary modifications for protection 
from cold — be applicable in temperate climates for hospital 
purposes, where temporary accommodation for a limited 
period was wanted. 

The object of this book, however, is not to give actual 
designs for hospitals, but to suggest the principles which 
should govern their design. These principles, if rightly appre- 
ciated, would apply as much to the creation of a permanent 
as to that of a temporary hospital. 

Conclusion. 

A considerable development has been taking place in the 
construction of hospitals in late years, especially in England, 
France, Germany, and America, and it seems probable that 
this activity will continue in this country under the influence 
of the County Councils and other bodies to whom the 
management of local affairs are being by degrees entrusted. 
The time therefore appeared to be opportune for bringing to 
a focus those principles which educated experience has shown 
to be essential, if we are to deprive of their powers of mischief 



282 Healthy Hospitals. 

those agencies which always seem to arise from the congrega- 
tion of many persons under one roof; and, at the same time, 
to place the subject in a form which might be helpful to the 
medical man and the architect, as well as to those who are 
charged with obtaining the funds necessary for the erection of 
hospitals. 

It has been a matter of regret that whilst so much sickness 
and misery prevails which can be alleviated by the extension 
of hospitals, the cost of their construction has risen to almost 
prohibitory sums. This has not resulted entirely from the 
increased appreciation of the importance of providing light, 
air, and warmth, which are the first essentials of hospital 
construction, but it has been partly due to the desire to erect 
palatial structures, which shall impress the eye and become 
a standing advertisement of the originator or of the architect 
of the hospital. 

The principles enumerated in this book are not new ; they 
are well known, but they lie somewhat scattered through 
various publications, and the object of this treatise has been 
to bring them together, and by showing what points are 
essential to health in hospital construction, to enable those 
upon whom the regulation of the construction devolves to 
concentrate expenditure upon these matters alone. 

It is hoped that by bringing together this information, the 
erection of large, palatial hospitals in towns or other localities 
which are not suited to them will be discountenanced, and 
that the hospital architect, instead of seeking to erect a monu- 
ment of his skill and taste in architectural design, will be 
content to provide simple structures abundantly supplied 
with light and air, in which the interests of the patients 
and their recovery will be not alone the first, but the only 
consideration. 



INDEX. 



A. 

Ablution basins, p. 218. 

— rooms, 217-220, 262. 
Accommodation hospitals, 7, 18, 19. 

— payment for, 10, 11. 
Administrative buildings, 239-252. 
Aeration of soil, 24. 

— of wards, 224. 
Agglomeration of sick, 3, 35. 
Aggregation of ward units, 224, 227. 
Air, aqueous vapour in, 38, 39. 

— burning (E. A. Cowper's process), 
67, 69-76. 

— capacity of, for moisture, 52. 

— CO2 in, 25, 39-46, 49, 50, 55. 
Billings' test, 42, 43. 

— change of, 49, 58, 78. 

— circulation of, 106, 148, 153. 

— composition of, 37-40. 

— currents, action of fireplaces and 
chimneys on, 81-84. 

— dust in, 38. 

— expansion of, 131. 

— filters, 62-64. 

— fresh, 6, 1 5. 

— ground, 24, 25. 

— measurement of, 59, 60, 84. 

— movement of (natural), 20, 77, 78, 
80, 82. 

by application of heat, 20, 78, 

84. 

by aspiration, 159-166. 

by propulsion, 92-99, 166-173. 

in chimney flues, 81, 86. 

— organic matter in, 44, 45-46. 

Angus Smith's test, 43. 

Carnelley's test, 44. 

— oxygen in, 37, 40, 45, ii5- 

— permeability of material to, 55-57. 

— pumps, 93, 94. 

— purification of (Key's process), 62- 
66. 

— quantity for ventilation, 20, 47, 55. 

— temperature of, 50, 51. 

— velocity of, 39, 59, 79. 
in shafts, &c., 79, 82, 84. 

— vitiation of, 20, 35, 37, 39, 40-46, 
49. 



Air, volume of, discharged by flue, 82, 

85, 89-91. 
fan, 92-95. 

— warming, 65, 89, 100, 114, 119, 124, 
127, 128. 

— weight of, 52, 77, 90, 115. 
Aitken, experiments on air and dust, 38. 
Anemometers, 60. 

Angus Smith, CO2 in air, 37. 

— organic matter in air, 43. 
Antwerp Exhibition, 277. 

— Hospital, 118, 167, 187, 188, 193, 
235. 

Area for site of hospital, 32, 35, 36, 237. 

Areas of existing hospitals, 33-35. 

Arnott's air-pump, 94. 

Ashes, 249. 

Avraches Marine Hospital, 255. 

Axis of wards, 227. 

B. 

Balconies and verandahs, 195, 235, 

273, 281. 
Banyuls-sur-Mer Marine Hospital, 255- 

257. 
Barnes Hospital, 160, 165. 
Baths, 213, 217, 218, 243, 262, 272. 
Beaujon Hospital, 166, 167. 
Bed-space, 48, 185-187, 194, 196, 199. 
Beds, apportionment to cases, 192. 

— proportion of, to population, 7. 
Berck-sur-Mer, 255. 

Berlin Military and Civil Hospitals, 

35, 193, 196. 

— Lying-in Klinik, 266, 267. 
Billings' test for CO2, 42, 43. 
Blackman's fan, 98, 157, 169. 
Bohm's ventilation, 157, 158. 
Bonn Hospital, 203. 
Bourges Hospital, 195. 
Bradford Hospital, 34. 
Breslau Clinical Hospitals, 196. 
Brydon, Mr., 236. 

Bunsen burner, 140. 

Burnley Hospital, 34, 149, 88-190. 



Candles, 141. 

Cannes Marine Hospital, 257. 



284 



Index. 



Carbonic acid gas, 25, 39-46, 49) 50j 

66- 
Carnelley, Prof., 38-44, 210. 
Ceilings, 206, 208 
Cette Marine Hospital, 257. 
Charing Cross Hospital, 33. 
Children's hospitals, 13, 224, 254-258. 
Chimneys, proportions for, 86. 
Cholera, 8, 21. 
Circular wards, 187-191. 
Clay soil, 26, 29. 
Cleanliness, 15-17, 79, 80, 267. 

— of soil, 27. 

Close stoves, 134, 135. 
Cockle, 114, 119, 155. 
Colchester Military Hospital, 186, 231, 

232. 
Conclusion, 281, 282. 
Conducting power of materials, 103, 

104. 
Conduction of heat, 100. 
Connexion of ward unit, 230. 
Convalescent hospitals, 13, 22, 254, 260- 

263. 
Convection of Heat, 100. 
Corridor system of hospital, 4, 199. 

— between pavilion, 231, 235. 
Cottage hospitals, 2, 13, 22, 224. 
Cowls, 83. 

Cowper, E. A., burning ward air, 69-76. 
Crane's destructor, 249-251. 
Cubic space, 47, 55, 187- 

D. 

Daeker hospitals, 2 78. 

Day and sun rooms, 195, 196. 

Daylight, 138. 

De Chaumont experiments, 42, 58. 

Derby Infirmary, 155, 156, 230. 

Destructor, Crane's, 249-251. 

Dispensaries, 14. 

Distance between pavilions, 177, 228. 

Distribution of heat, 149-157. 

Donkin's formulae for impurity of air, 

49. 
Doors, 204, 205, 239. 
Drainage, 220-222. 
Dresden Hospital, 181. 
Drug stores, 240. 
Dust in air, 38. 



Early history of hospitals, i, 2. 
Earth closet, 281. 
Eastern Hospital, Homerton, 35. 
Economy of construction, 192, 213, 

222, 229, 239, 282. 
Edinburgh Infirmary, 34. 
Emmerich, Prof., 210. 



Fans, Blackman, 98, 157, 169. 

— Rittinger and Combes' formulae, 94, 
96. 

— rotary, 94, 95. 
■ — screw, 95, 96. 

Field hospitals, 3, 5, 6, 276, 277. 
Filters in air, 62-64. 
Flame, 140, 141. 

— temperature of, 102. 
Floor-space, 47, 48, 183-187. 
Floors, 208-212. 

— cleaning, 212. 

— non-absorbent, 212. 

— organic matter in, 209, 210. 

— raised, 181, 209. 

— warmed, 151. 

— wood, 211. 

Formula for weight of air discharged 
from flues, 90. 

— for area of flue, 90. 
Friction in air shafts, 82. 
Friederichshain Hospital, 196. 



Gas-light, 140. 

Glasgow Western Infirmary, 34, 169- 

171. 
Glass, loss of light through, 201. 

— heat, 202. 

Gottingen Hospital, 203, 241, 242. 
Grates, Rumford, 107, 108. 

— Gallon, 109, 112. 

— Saxon Snell's Thermhydric, 112, 113. 

— Sylvester, 107. 

— Teale (Lionel), 108. 
Gravel soil, 26, 27. 
Grease trap, 248. 
Ground air, 24, 25. 

H. 

Haldane, experiments on air, 38, 41. 
Hamburg Hospital, 150-156, 175, 193, 

209. 
Harston, Messrs., architects, 230. 
Healthiness of site, 22-30. 
Heat, conduction of, 100. 

— convection of, 100. 

■ — distribution of, 149-15 1. 

— loss of, 104. 

— radiation of, loi, 102, 133. 
Heat imits, 131. 

Heating apparatus, 88, 89, 102, 103, 

105-113. 
Herbert Hospital, 109-112, 193. 
Holywood Hospital, Belfast, 226, 227. 
Hopkins {see Johns Hopkins). 
Hospitals, accommodation, 7, 18, 19. 

— children's, 13, 224, 254-258. 



Index. 



285 



Hospitals, classification of, 13. 

— convalescent, 13, 22, 254, 260-263. 

— corridor system of, 4, 199. 

— cottage, 3, 13, 22, 224. 

— Daeker, 278. 

— definition of, 9. 

— early history of, 1, 2. 

— field, 3, 5, 6, 267, 277. 

— general, 13. 

— infections, 13, 31, 249, 254, 263, 264. 

— iron, 278. 

— isolation, 2, 22, 224. 

— lying-in, 1,13, 265-274. 

— maintenance of, 10, 11. 

— marine, 13, 22, 255-257. 

— Metropolitan Asylums Board, 7, 
35. 67. i83> 230, 249. 

— military, i, 147, 187, 226, 232, 280. 

— origin of present construction, 3. 

— pavilion system of, 4, 174, 199, 227. 

— small-pox, 31, 32, 66. 

— wood, 278. 

Hot-water pipes, 88-91, 100, 121-128, 

134. 135- 

— high pressure, 127, 128. 

— low pressure, 124-126, 135. 
Human body, temperature of, 50. 
Humidity, 51-55. 

I. 

Imbeciles, 14, 22. 
Incurables, 14, 254. 
Infection, 15, 254, 263. 
Infectious Hospitals, 13, 31, 254, 263, 
264. 

— probationary wards in, 225, 263. 

— protection to public, 264. 

— protection to staff, 264. 
Infirmaries, workhouse, 14. 
Inlets, 79, 146, 170, 197. 
Inquest room, 243. 
Isolation hospitals, 2, 22, 224. 

— wards, 225, 263, 273. 

J- 

Jebb, Sir Joshua, 160. 

Johns Hopkins Hospital, 34, 161-164, 

181, 194, 196, 209, 225, 227. 
Johnston, Miss, 210. 

K. 

Key's air- washing screen, 62-64. 

— system of ventilation, 169-171. 
King's College Hospital, 33. 
Kitchen, 247, 248, 263. 

L. 

Lariboissiere Hospital, 166. 
Laundry, 249. 



Leeds Hospital, 33. 
Leroux, Dr., 257. 
Lifts, 213, 236. 
Light, 15. 

— artificial, 139-144. 

— candle, 53, 141. 

— day, 138, 139. 

— electric, 144. 

— gas, 53, 140- 

— loss of, through glass, 20 x. 

— proportion in room, 198. 
Limit of size of hospital, 237. 
Linen, 215, 249. 
Liverpool Hospital, 34. 
Lunatics, 14, 22. 

Lying-in hospitals, 1,13, 265-274. 

M. 

Maintenance of hospitals, 10, 11. 

— patients, 247. 
Margate Hospital, 255, 

Marine Hospital, 13, 22, 255-257. 
Marston, Surgeon-General, 279-281. 
Marylebone Infirmary, 33, 193. 
Measurement of air, 59, 60, 84. 
Medical school, 245, 246. 

— student, education of, 9, 10. 
Menilmontant (Tenon) Hospital, 35, 

167, 175, 193. 266. 
Metropolitan Asylums Board, 7, 35, 67, 

183, 230, 249. 
Middlesex Hospital, 33. 
Miguel, Dr., bacteria in air, 38. 
Military hospitals, i, 147, 187, 226, 

232, 280. 
Moabit Hospital, 200. 
Mons Hospital, 235. 
Montpelier Hospital, 35, 175, 178, 

181, 182, 184, 185, 193, 209. 
Morin, General, 84, 160. 
Mortuary, 243, 244. 
Movement of air, by application of heat, 

20, 78, 84. 

— by aspiration, 139-166. 

— by natural means, 20, 77, 78, 80, 82. 

— by propulsion, 92-99, 166-173. 

— in chimney flues, 8x, 86. 

N. 
Necker Hospital, 166. 
New York Hospital, 34, 168, 247. 
Nightingdale, Miss, lying-in hospital, 
267. 

— Notes on hospitals, 192, 213. 

— Quain's Dictionary, nursing, 14, 198. 
Nitrogen, 37, 115. 

Norfolk and Norwich Hospital, 175, 

193- 
North-Western Hospital, Haverstock 

Hill, 35- 



286 



Index. 



Number of patients, medical, 1 74. 

— per acre, 32. 

— per ward, 174, 175. 

— surgical, 1 74. 

— under one roof, 174, 176, 237. 
Nurses, 214, 252. 

Nursing, 191. 

— cost per bed of, 192. 

O. 

Operating theatre, 240-243. 
Organic matter in air, 44-46. 
Outlets, 79, 146, 170, 197. 
Out-patient's department, 245-247. 
Oxygen, i^, 40, 45, 115. 



Patients, separation of, 12, 13, 194. 

Pavilion system of construction, 4, 1 74, 
199, 227. 

Peach, Mr., 107, 245. 

Peclet formula for co-efficient of resist- 
ance, 85. 

— windows, 202, 
Percolation, 26. 

Perkins, hot-water pipes, 127. 

Philadelphia Field Hospital, 5. 

Pipes, hot-water, 88-91, 100, 121-128, 

134' 135- 

— steam, 89, 91, 128, 135. 
Play-rooms, 262. 
Porosity of materials, 55-57. 
Post-mortem room, 243-245. 
Probationary wards, 225, 263. 
Probationers, 253. 

Propulsion of air, 92-99, 166-173. 
Proximity of adjacent wards, 228. 
Pumps, air, 93-95. 

Putman, experiments on porosity of 
walls, 57. 

Q. 

Quain's Dictionary — Nursing, 198. 

R. 

Radiation in heat, 101, 102, 133. 

Ratio of infectious sick to population, 7. 

Reception of patients, 239. 

Red Cross Society, 277. 

Refuse, 215, 248, 249, 263. 

Renne-Sabran, 255. 

Ridge ventilation, 178-180. 

Roofs, 206, 279. 

Rudolf Stift, 157. 

Rumford grate, 107, 108. 

Rumsey, Dr., 174. 

Russell, Dr., CO2 in air, 38. 



St. Denis Hospital, 180, 181, 193. 

St. Eloi (Montpelier) Hospital, 35, 175, 

178, 181, 182, 184, 185, 193, 
St. George's Hospital, 33. 
St. Pol-sur-Mer, 257. 
St. Thomas' Hospital, 34, 175, 193. 
Sanatoria, 258-260. 
Saxon Snell's Thermhydric grate, 112, 

113- 

Scullery, ward, 214, 271, 272. 
Separation of patients, 12, 13, 194. 

— ward unit, 229. 
Servants in hospitals, 251. 

Shafts for ventilating, 81-84, 86-88, 
147, 158. 

— velocity in, 84, 85, 148. 
Sherringham ventilator, 146. 
Sick, agglomeration of, 3, 35. 
Site, accessibility of, 21. 

— area per patient, 32, 35, 36. 

— compulsory purchase of, 36. 

— drainage of, 24. 

— elevation of, 23. 

— healthiness of, 22-30. 
Smallpox hospitals, 31, 32, 66. 
Smead, air-warmer, 119. 

— system of ventilation, 157. 
Soil, 16. 

— aeration of, 24. 

— cleanliness of, 25, 27. 

— disturbance of, 28. 

— level of water in, 24, 28. 

— porous, 29. 

— vapour from, 27. 
South-Eastern Hospital, 35. 
South- Western Hospital, 35. 
Splint room, 240. 
Staircases, 230-236. 

Steam pipes, 89, 91, 128-132. 

— exhaust steam, 132. 

— high pressure, 128. 

— low pressure, 129. 
Stores for clothing, 216, 249. 
Stoves, 135. 

Subways, 236. 
Sunshine, 174, 198. 
Surgeon's room, 214, 252. 
Sylvester grate, 107. 

— system of ventilation, 155, 160. 



Teale (Lionel) grate, 108. 

Temperature, 50, 51. 

Tenon (Menilmontant) Hospital, 35, 

167, 175, 193, 266. 
Toilet, Mons., 83, 159. 
— ward, 181. 
Trowbridge's formulae, 89-91. 



Index. 



287 



u. 

Unit of hospital construction, i8, 174. 
University College Hospital, 33. 
Urinals, 219. 

V. 

Van Heecke's method of propulsion, 

167. 
Vapour, 27, 51. 
Velocity of air-currents in shafts, 79, 

82, 84, 88. 
Ventilation, 41. 

— arrested, 49. 

— aspiration, 159-166. 

— fireplaces for, 105. 

— propulsion, 92-99, 166-173. 

— ridge, 83, 159, 178-180. 

— shafts for, 81-84, 86-88, 147, 158. 

— Snaead, 157. 

— Sylvester, 155, 160. 

— windows for, 198, 202, ■203. 
Ventilators, Bohm's, 157, 158. 

— Hopper, 146. 

— Moore's, 146. 

— Sherringham's, 146. 

— vertical tubes, 81, 147. 

— Watson's, 84. 

Verandahs and balconies, 195, 235, 273, 

281. 
Ver-sur-Mer, 257. 
Victoria Hospital, Glasgow, 169. 

W. 

Waddington, Mr., architect, 189. 
Walls, 205-208, 219. 
Ward offices, 213, 220. 

— for nursing, 214-216. 

— for use of patients, 216. 



Ward ofifices, in proportion to wards, 

222. 
Ward unit, 174-224. 

— aggregation of, 224-227. 

— connexion of, 231. 

— separation of, 229. 
Wards, at rest, 224, 273. 

— circular, 187, 189, 191. 

— form of, 3, 19, 178-181, 187-191. 

— number of beds in, 175, 176, 192- 

195- . 

— probationary, 225, 263. 

— rectangular, 189. 

— size of, 19, 185. 
Warmed floors, 136, 151. 
Warming, ico-137. 

— by close stoves, 134. 

— by a cockle, I14, ii8, 119, 155. 

— by hot-water pipes, 88-91, 100, 121- 
128, 134, 135. 

— by Smead furnace, 119. 

— by steam pipes, 89, 91, 128-132. 
Waste-pipes, 215. 

Water-closets, 217, 220, 253, 258, 262. 
Watson's ventilator, 84. 
Weight of air, 52, 77, 90, 115. 
Western Hospital, Fulham, 35, 228, 

233- 
Windows, 146, 198-204. 

— double, 201, 202. 

— loss of heat through, 201. 
Women's Hospital, Euston Road, 235. 



Young, Keith, Mr., 233. 



Z. 

Zone of aeration, 177, 183. 



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